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UNLV Theses, Dissertations, Professional Papers, and Capstones
5-1-2014
The Lived Experience of Black African Nurses Educated Within the The Lived Experience of Black African Nurses Educated Within the
United States United States
Amy Elizabeth Smith University of Nevada, Las Vegas, [email protected]
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THE LIVED EXPERIENCE OF BLACK AFRICAN NURSES
EDUCATED WITHIN THE UNITED STATES
by
Amy E. Smith
Bachelor of Science in Nursing
South Dakota State University
1998
Master of Science in Nursing
Walden University
2007
A dissertation submitted in partial fulfillment
of the requirements for the
Doctor of Philosophy – Nursing
School of Nursing
Division of Health Sciences
Graduate College
University of Nevada, Las Vegas
May 2014
Copyright by Amy E. Smith, 2014
All Rights Reserved
ii
THE GRADUATE COLLEGE
We recommend the dissertation prepared under our supervision by
Amy E. Smith
entitled
The Lived Experience of Black African Nurses Educated Within the United States
is approved in partial fulfillment of the requirements for the degree of
Doctor of Philosophy - Nursing
Department of Nursing
Tish Smyer, DNSc, Committee Chair
Alona Angosta, Ph.D., Committee Member
Lori Candela, Ed.D., Committee Member
LeAnn Putney, Ph.D., Graduate College Representative
Kathryn Hausbeck Korgan, Ph.D., Interim Dean of the Graduate College
May 2014
iii
ABSTRACT
The Lived Experience of Black African Nurses
Educated Within the United States
by
Amy Smith
Dr. Tish Smyer, Examination Committee Chair
Professor of Nursing and Associate Dean for Academic Affairs
University of Nevada, Las Vegas
Despite the unprecedented growth of minority populations in the United States,
the nursing profession has remained relatively homogenous. Nursing education has
increased the number of minority students entering nursing programs; however, attrition
rates for minority nursing students are as high as 85% (Gilchrist & Rector, 2007). As the
population grows in diversity, the need for nurses who are fluent in foreign languages and
who understand minority values, traditions, and cultural practice will be essential in
delivering culturally competent care. Improving the retention of minority nursing
students is an important step in increasing the diversity within the nursing workforce.
Although several studies have addressed the retention of minority students, few
have addressed retention from an individual-minority standpoint. Cultural competence in
education requires that the unique characteristics of individuals’ values and beliefs be
considered. Black Africans are among the fastest growing immigrant and refugee
populations in the United States, and literature relating to their experiences in nursing
education in the United States is scarce. The purpose of this study was to gain an
understanding of how black African nurses experience nursing education within the
United States. Understanding how black Africans experience nursing education is the
iv
first step in identifying factors and strategies that impact the retention of this specific
minority population.
A phenomenological approach using Max van Manen’s (1990) six research
activities guided this study. Van Manen’s approach was operationalized through the use
of Colaizzi’s (1078) seven-step method of qualitative analysis. Guba’s (1981) process
was used to establish trustworthiness by addressing credibility, transferability,
dependability, and confirmability. The question guiding this study was as follows: How
do black Africans experience nursing education within the United States?
Nine black African nurses voluntarily participated in this study. Participants had
all emigrated from a sub-Saharan African country, were currently working as registered
nurses, and had attended a pre-licensure registered nursing program in the United States.
Optimistic determination was identified as the main essence of the participants’
experience. From this essence, four main themes and 13 sub-themes provided a rich
description of the phenomenon. Bandura’s (1997) theory of social cognitive development
and Leininger’s (2001) theory of nursing were used as a basis for recommendations for
the creation of a culturally competent educational environment. Through this awareness,
strategies may be introduced that support the retention and success of black African
nursing students, and build the diversity of the nursing workforce.
v
ACKNOWLEDGEMENTS
I could not have achieved this success without the help from God, faculty, family, and
friends. It is only by the grace of God that I have been given the opportunities I have, and
for that I am most thankful.
Thank you to my dissertation committee for the insight and support you provided
along the way. Your knowledge and experience are inspiring, and I hope to live up to
your expectations as a UNLV PhD graduate. In particular, thank you to my chair Dr.
Smyer for being so patient with my daily e-mail questions, and to both Dr. Smyer and Dr.
Putney for keeping me grounded and focused when I was drowning in data analysis.
Thank you to the University of South Dakota nursing program for its incredible
financial and emotional support. I am so proud, and grateful, to be part of such an
innovative program that truly values their faculty.
Thank you to my husband for putting up with a very crabby wife when deadlines
were approaching, taking on extra household duties, and single-parenting. You are my
rock. Thank you to my two beautiful girls for your patience when Mom couldn’t always
be there, and for your hugs and kisses when I needed them the most. Thank you to Mom,
Dad, Don, and Jan, for always being there when I needed a little extra help or support.
All of you are a part of this degree.
Finally, I want to thank Mrs. Ruth Biedermann for believing in me at a time when
I was struggling in my nursing career. I had been a nurse less than a year and was ready
to throw in the towel. You took me under your wing and said, “You are going to do big
things.” You were my first mentor, and the first person in the nursing profession to show
me kindness. Your statement resonates with me to this day. Thank you for believing in
me. It doesn’t get much bigger than this!
vi
TABLE OF CONTENTS
ABSTRACT ....................................................................................................................... iii
ACKNOWLEDGEMENTS .................................................................................................v
LIST OF TABLES AND FIGURES................................................................................ viii
CHAPTER I: INTRODUCTION .........................................................................................1
Background and Significance ..........................................................................................1
Definitions........................................................................................................................3
Problem Statement ...........................................................................................................9
Purpose of Study ............................................................................................................10
Research Question .........................................................................................................10
Chapter Summary ..........................................................................................................10
CHAPTER II: LITERATURE REVIEW ..........................................................................12
Building a Diverse Nursing Workforce .........................................................................12
Black African Migration Within the United States........................................................16
Health Beliefs and Practices Among Black Africans ....................................................18
Nursing Practice Within the Black African Immigrant Population ...............................21
Chapter Summary ..........................................................................................................23
CHAPTER III: METHOD OF INQUIRY GENERAL .....................................................24
Historical Foundations of Phenomenology ...................................................................25
Researching Lived Experience by Max van Manen .....................................................26
Phenomenological Activities Related to This Study ....................................................27
Participant Selection .....................................................................................................30
Data Generation and Analysis Procedures ....................................................................31
Ensuring Trustworthiness ..............................................................................................35
Chapter Summary .........................................................................................................37
CHAPTER IV: METHOD OF INQUIRY APPLIED .......................................................38
Participant Recruitment and Selection ..........................................................................38
Gaining Access ..............................................................................................................40
Data Generation and Analysis Procedures ....................................................................42
Ensuring Trustworthiness and Authenticity ..................................................................46
Chapter Summary ..........................................................................................................47
vii
CHAPTER V: FINDINGS .................................................................................................48
Description of Participants ............................................................................................48
Data Collection .............................................................................................................48
Data Analysis ................................................................................................................51
Essence, Themes, and Sub-Themes ..............................................................................51
Chapter Summary ..........................................................................................................91
CHAPTER VI: DISCUSSION AND INTERPRETATION ..............................................92
Findings as They Relate to the Current Literature ........................................................92
Implications for Nursing ..............................................................................................107
Limitations ..................................................................................................................110
Recommendations for Further Research .....................................................................110
Chapter Summary .........................................................................................................111
CONCLUSION ................................................................................................................111
APPENDICES .................................................................................................................113
Appendix A: Summary of Literature ...........................................................................113
Appendix B: Demographic Questionnaire ...................................................................127
Appendix C: Interview Questions ................................................................................128
Appendix D: Recruitment Flyer ...................................................................................129
Appendix E: Informed Consent and Audio Taping Consent .......................................130
Appendix F: Demographic Characteristics of Participants ..........................................133
Appendix G: IRB Approval .........................................................................................134
Appendix H: Comparison of Sanner et al. (2002) and Smith (2014) ...........................135
REFERENCES ................................................................................................................137
CURRICULUM VITA ....................................................................................................146
viii
LIST OF FIGURES
Figure 1. Map of East Africa ...............................................................................................4
Figure 2. Map of Middle Africa ...........................................................................................5
Figure 3. Map of North Africa .............................................................................................6
Figure 4. Map of Southern Africa .......................................................................................7
Figure 5. Map of Sub-Saharan Africa ..................................................................................8
Figure 6. Map of West Africa ..............................................................................................9
Figure 7. Model Depicting the Lived Experience of Black African Nurse Educated
Within the United States ....................................................................................52
1
CHAPTER I
INTRODUCTION
Background and Significance
Diversity within the United States population has reached unprecedented
proportions. According to Minkler (2008), nearly one third of the U.S. population claims
minority status, an 11% increase from 2000 to 2007. Recent projections from the 2010
census indicate that by 2043, the white majority population will claim minority status,
with no single race claiming the majority (U.S. Census Bureau, 2013). Despite the
growth in diversity within the general population, the nursing workforce remains
relatively homogenous. Diversity is important within nursing because studies show that
improved patient outcomes are achieved when diverse people interact with healthcare
personnel from similar ethnic and racial backgrounds (American Association of Colleges
of Nursing, 2010; Institute of Medicine, 2003; The Sullivan Commission, 2004).
Nurses enter the profession through nursing education programs and the NCLEX
licensure examination. Therefore, education would be a logical place to begin the task of
increasing diversity within the nursing workforce. The volume of literature related to
recruitment and retention of minority nursing students is overwhelming, to say the least.
Despite the volume of work in this subject area, there has been little improvement in the
percentage of diverse nurses working in the United States. Furthermore, attrition rates
continue to be high among minority nursing students (Gilchrist & Rector, 2007; National
Advisory Council on Nurse Education and Practice, 2001). The lack of growth in
minorities in the nursing profession, as well as a high attrition rate for minority students,
would indicate that a different approach is needed to address these challenges.
2
One reason for the lack of progress in diversifying the nursing workforce could be
the limited number of studies relating to the experiences of individual minority
populations within nursing education. Cultural competence demands that nurses make
decisions based on the unique values, beliefs, and behaviors of the individual (American
Association of Colleges of Nursing, 2008; The Sullivan Commission, 2004). However,
nursing education literature often studies ethnically diverse students in silos such as
“minority,” “immigrant,” or “English-as-a-second-language” without any regard for their
individual cultural characteristics. Therefore, understanding the unique needs of specific
ethnic populations is paramount to creating educational programs that are truly culturally
competent and that support the growth of a diverse nursing workforce.
Black Africans are one of the fastest growing immigrant and refugee populations
in the United States, increasing by 200% in the 1980s and 1990s, and by 100% in the
2000s (Migration Policy Institute, 2012). Recent demographic data reports that although
12.2% of the population identifies as Black or African American, only 5.4% of the
nursing population places itself in the same category (U.S. Department of Health and
Human Services Health Resource Association, 2010). This minority gap is second only to
the Hispanic population. Health disparities are drawn against racial and ethnic lines
(Institute of Medicine, 2003; The Sullivan Commission, 2004). In order to reduce health
disparities among black Africans, it is necessary to promote a workforce that can address
the unique needs of this population. As part of one of the fastest growing immigrant and
refugee populations, more black African nurses are needed to deliver culturally
competent care to citizens of a similar racial and ethnic background.
3
Definitions
The following definitions describe terms used throughout the study:
Black African
A black African is person from the sub-Saharan region of Africa who is black.
Cultural competence
Cultural competence is the ability to make patient care and administrative decisions
based on the context of the consumer in relation to values, beliefs, and behaviors (The
Sullivan Commission, 2010; American Association of Colleges of Nursing, 2008).
Diverse
The term diverse refers to inherent differences in race/ethnicity, gender,
socioeconomic status, disability, sexual orientation and preference, and geography (U.S.
Department of Health and Human Services, 2010).
East Africa
East Africa refers to a part of sub-Saharan Africa bordered by the Indian ocean on the
east and the Saharan desert on the north, which includes the countries of Burundi,
Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mayotte,
Mozambique, Reunion, Rwanda, Seychelles, Somalia, South Sudan, Uganda, United
Republic of Tanzania, Zambia, and Zimbabwe (United Nations, 2013; see Figure 1).
4
Immigrant
The United States Immigration and Nationality Act of 1952 defines the term
immigrant as every alien except one entering the country for explicit purposes of transit,
employment, and/or education. The term alien is defined as any person not a citizen or
national of the United States (Immigration and Nationality Act, 1952). This is an
important consideration when forming a definition of immigrant. Because a refugee is an
alien and does not fit the exceptions provided, for the purpose of this study, the term
immigrant will be inclusive of both the general immigrant and refugee population, unless
otherwise noted.
Figure 1. Map of East Africa
(Maps of World, 2012b)
5
Middle Africa
Middle Africa refers to the central region of Africa that includes the countries of
Angola, Cameroon, Central African Republic, Chad, Congo, Democratic Republic of
Congo, Equatorial Guinea, Gabon, and Sao Tome and Principe (United Nations, 2013;
see Figure 2.)
North Africa
North Africa refers to north-most region of the African continent. This area includes
the countries of Algeria, Egypt, Libya, Morocco, Sudan, Tunisia, and Western Sahara
(United Nations, 2013; see Figure 3).
Figure 2. Map of Middle Africa
(Maps of World, 2012a)
6
Refugee
A refugee is any person outside his or her country of origin who is unwilling or unable
to return because of persecution or a well-founded fear of persecution on account of race,
religion, nationality, membership in particular social group, or political opinion
(Immigration and Nationality Act, 1952).
Southern Africa
Southern Africa refers to the southernmost region of the African continent, which
includes the countries of Botswana, Lesotho, Namibia, South Africa, and Swaziland
(United Nations, 2013; see Figure 4).
Figure 3. Map of North Africa
(Maps of World, 2012c)
7
Sub-Saharan Africa
The sub-Saharan region of Africa refers to the area of Africa south of the Saharan
desert. It includes all African countries with the exception of Algeria, Egypt, Libya,
Morocco, Tunisia, and Western Sahara (United Nations, 2013). Immigrants from South
African regions are predominately white, well-educated, and speak English as their
primary language (Capps, McCabe, & Fix, 2011). Therefore, for the purposes of this
study, reference to sub-Saharan Africa excludes the southern African nations of
Zimbabwe, Mozambique, Zambia, Namibia, South Africa, Botswana, Madagascar, and
Mozambique (see Figure 5).
Figure 4. Map of Southern Africa
(EWT, 2013)
8
West Africa
West Africa is an area of Africa bordered by the Atlantic Ocean on the south and west,
and the Saharan desert on the north. The area includes the countries of Benin, Burkina
Faso, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Equatorial Guinea, The Gambia,
Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra
Leone, and Togo (United Nations, 2013; see Figure 6).
Figure 5. Map of Sub-Saharan Africa
(“This Is Sierra Leone,” 2012)
9
Problem Statement
Despite interventions aimed at increasing diversity within the nursing workforce,
there has been little gain in the number of minority nurses over the last two decades.
Research and interventions have focused on minorities in the general sense, and very
little is known about the specific experiences and needs of individual minority
populations. Black Africans are among the fastest growing groups of immigrants within
the country. Therefore, recruiting and retaining nurses from this population will be
essential in meeting the healthcare needs of the general population. Nursing education is
considered by many to be the gateway to the profession. An understanding of the
experiences of black African nurses educated in the United States can lead to the
Figure 6. Map of West Africa
(Maps of World, 2012d)
10
development of interventions that aid in retention, successful entry into practice, and a
growth in diversity within the nursing profession.
Purpose of Study
The purpose of this phenomenological inquiry is to gain an understanding of how
black African nurses experience nursing education within the United States.
Understanding experiences from the participants’ perspectives can provide insight into
factors that affect the recruitment and retention of this specific minority population.
Through the identification of these factors, targeted changes in the development of
administrative and curricular support can occur, resulting in significant gains in
workforce diversity that more closely mirror proportions seen within the general
population.
Research Question
The research question used to guide this study is as follows: How do black
African nurses experience nursing education within the United States?
Chapter Summary
This chapter provided background information for the proposed study,
identification of the problem, and the research question. The growth in black African
nurses practicing in the United States has not kept pace with the growth of the same
segment of the general population. More black African nurses are needed to address
health disparities that run along racial and ethnic lines. High attrition rates among
minority students in nursing programs within the United States present a valid argument
for the study of the experience of black African nurses’ experience with nursing
education. Chapter II provides an analysis of the current literature related to the education
11
of black African nurses and identifies specific gaps that will be addressed through the
proposed study.
12
CHAPTER II
LITERATURE REVIEW
A review of the nursing literature related to black African nurses educated within
the United States began by using the computerized databases CINAHL, Medline,
Academic Search Premier, and Pub Med. Search results were limited to the years 2000–
2013 to assure information was current and timely. The initial search used variations of
terms related to the research question. Library services at the University of South Dakota
and the University of Nevada–Las Vegas were used to help identify keywords and
appropriate search terms. This initial search resulted in no results related to the research
purpose. As a result of the limited amount of information related to the initial search
terms, the search was expanded to include topics that were believed to influence the
success of black African immigrants within nursing education. These topics included
nursing workforce diversity, health beliefs, and nursing practice. A comprehensive table
of the literature can be found in Appendix A.
Building a Diverse Nursing Workforce
The literature is replete with information relating to the need to diversify the
nursing workforce. All major government, hospital, nursing, and educational
organizations attest to the importance of mirroring the demographic composition of the
general population in order to reduce health disparity and provide culturally competent
care (American Association of Colleges of Nursing, 2011; Institute of Medicine, 2003;
National Advisory Council on Nurse Education and Practice, 2001; National League for
Nursing, 2009; The Sullivan Commission, 2004). Strategies to address workforce
diversity have focused primarily on academia and demonstrate the need for a
13
multifaceted approach. Common themes include financial support, recruitment and
retention of diverse students, and the development of a diverse nurse faculty pool (Brown
& Marshall, 2008; Evans, 2007; Escallier & Fullerton, 2009; Gilchrist & Rector, 2007;
Noone, 2008; Wilson, Sanner, & Lydia, 2010; Wilson, Andrews, & Leners, 2006).
Mentoring and the development of cultural competency among faculty were found to be
the most commonly documented strategies for the retention of minority students (Evans,
2007; Wilson et al., 2010).
Despite the support and focus on closing the gap with respect to nursing
workforce diversity, only a modest gain has been experienced (U.S. Department of
Health and Human Services Health Resource Association, 2010). Currently, ethnically
diverse populations represent 37% of the general population, but only 16.8% of the
registered nurse population in the United States indicates that there is still much work to
be done (U.S. Census Bureau, 2013; U.S. Department of Health and Human Services
Health Resource Association, 2010). Even more concerning, enrollment of ethnically
diverse pre-licensures nursing students has dropped from 29% to 24% over the last two
years (National League for Nursing, 2012). Combined, this data indicates that current
strategies are not effective in increasing the proportion of ethnically diverse nurses
practicing within the United States.
Information and studies related to workforce and educational diversity focus on
general descriptions of ethnicity and often group many populations together under one
term. Because this study focuses on the black African immigrant population, it is
important to determine the state of science related to the education and nursing practice
of this specific population.
14
The literature search returned little information relating to black African
immigrant nurses within the United States. Much of what is known about this population
is included under a general categorization of black/African American, which does not
adequately describe the target population. Black African immgrants differ from African
Americans in that they are foreign born, often speak a primary language other than
English, and have experienced healthcare in ways different from African Americans
(Venters & Gany, 2011). These differences make a true scope of the problem difficult to
ascertain because no data specifically delineates the number of black African immigrants
enrolling and graduating from programs of nursing or practicing nursing within the
United States. However, general statistics related to black/African Americans would
support the need for further intervention and study.
Currently, 5.4% of the nursing workforce is composed of black/African
Americans compared to 12.2% of the general population (U.S. Census Bureau, 2013;
U.S. Department of Health and Human Services Health Resource Association, 2010).
Similar gaps in the literature exist in relation to enrollment and retention of black/African
Americans in nursing education programs. Although enrollment data for black/African
Americans in basic RN programs within the United States ranges from 14.5% in 2003 to
10.8% in 2009, graduation rates for the same population are estimated at 7.3% from 2001
to 2008 (National League for Nursing, 2012; U.S. Department of Health and Human
Services Health Resource Association, 2010).
Studies relating to the recruitment and retention of minority students were many;
however, only one of these studies identified an exclusive black African immigrant
population. Sanner, Wilson, and Samson (2002) studied the perceptions and experiences
15
of eight female Nigerian students enrolled within a baccalaureate nursing program and
identified themes of social isolation, resolved attitudes, and persistence despite perceived
obstacles.
Results from Sanner et al.’s (2002) study make generalizations difficult.
Participants were recruited after successfully completing two nursing courses, so it is
unknown whether the themes and factors identified by the participants truly affected their
ability to successfully complete their program, pass the NCLEX exam, and successfully
enter practice. Furthermore, results were limited to students enrolled in the same
university, and therefore the experiences identified may not reflect all locations and
levels of nursing education. Researchers used a guided interview technique that may
prevent participants from fully expressing their viewpoints and experiences (Gall, Gall, &
Borg, 2003). Although small sample sizes are consistent with qualitative research,
additional studies are needed to validate findings and allow transferability to the greater
black African immigrant population.
The evidence relating to diversification of the nursing workforce relies heavily on
statistical data gathered through government survey, opinion, and expository articles.
Research focusing on retention of minority students within the nursing workforce is
largely qualitative with small sample sizes and mixed races. Specific research dedicated
to the recruitment and retention of black African immigrant nursing students is extremely
limited and may not be transferrable to the entire black African population.
Understanding the perspective of the successful nurse graduates across different
education levels and facilities will add important value to this body of research.
16
Black African Migration Within the United States
Understanding trends and patterns in immigration can guide research in terms of
sample identification and recruitment strategies. The literature revealed a significant
amount of descriptive data related to black African immigration within the United States,
primarily from government sources. Currently, black African immigrants are one of the
fastest growing groups of United States immigrants, increasing by 200% in the 1980s and
1990s, and by 100% in the 2000s (Capps et al., 2011). Three quarters of all black African
immigrants are from sub-Saharan African countries, with the highest number originating
from Nigeria, Egypt, Ethiopia, Ghana, and Kenya (Remington, 2008; Terrazas, 2009).
Although the top states of settlement for all black African immigrants are New York,
California, Texas, Maryland, and Virginia, Minnesota welcomes the largest population of
Somali residents in the country and ranks ninth nationally in terms of African immigrant
populations (Remington, 2008; Terrazas, 2009). In fact, one fifth of all immigrants
entering the upper Midwest are black Africans (Remington, 2008). This large
concentration of black African immigrants would make this area ideal in locating a
sample for study.
Black Africans are more likely than all other immigrants to have entered the
United States as refugees (Capps et al., 2011). The term refugee refers to an immigrant
who has fled and is unable to return to his or her country of origin because of an actual or
well-founded fear of persecution. Approximately 28%, or one quarter, of black African
immigrants has entered the United States as refugees (Capps et al., 2011). Refugees often
experience conditions that are much different from those of the general immigrant
population. They often arrive traumatized by long-term settlement in refugee camps,
17
brutal murders of family members, sexual assault, poverty, and war (Palinkas et al.,
2003). Although the term immigrant includes refugees for the purpose of this study, it is
important to draw attention to the experiences that differentiate refugees from immigrants
in order to draw true meaning from the data gathered.
Black African immigrants fare well in terms of education and productivity. In
general, black African immigrants are well educated. According to Terrazas (2009),
42.5% of black African immigrants hold a bachelor’s degree or higher compared to the
27% average among all foreign-born adults in the United States. Although largely well-
educated compared to the general foreign-born population, black immigrants from Africa
are more likely to work in unskilled jobs below their level of education (Migration Policy
Institute, 2012; Obiakor & Afolayan, 2007; Terrazas, 2009; Venters & Gany, 2011). A
resolve to provide for their family results in black African immigrants having higher
employment rates than other foreign-born immigrants, but lower levels of earnings
(Capps et al., 2011; Obiakor & Afolayan, 2007).
In contrast to the general immigrant population, black African refugees have
lower levels of education, particularly those from Eritrea, Liberia, and Somalia, where
there is a disproportionate number of refugees (Capps et al., 2011). The constant struggle
to meet even the most basic needs of food, shelter, and safety leaves little time for
education. More than half of the refugees have less than a high school diploma
(Migration Policy Institute, 2012). A number of studies identify high rates of mental
health disorders that affect attention, short-term memory, and cognitive processes
(Buckley, Blanchard, & Neill, 2000; Murphy, Sahakian, & O’Carroll, 1998; Palinkas et
al., 2003). These factors have an affect on the ability of refugees to obtain education and
18
employment. The lack of education and financial resources, coupled with mental health
issues relating to trauma, is blamed for a high unemployment rate and a high rate of
poverty among black African refugees (Capps et al., 2011).
The evidence presented is reliable and makes a strong case for the recruitment and
retention of black African immigrants. As one of the fastest growing populations of
immigrants in the United States, this population will be expecting a healthcare workforce
that employs black African nurses that will understand their unique needs, values, and
beliefs. Although refugees experience challenges relating to education and productivity,
black African immigrants in general are well-educated people who have a desire and
willingness to work. This could have implications for both recruitment and persistence
within nursing school. Finally, black African immigrants may find nursing wages
appealing compared to the relatively low wages that many are settling for in order to
provide for their families. This earning potential could provide an additional motivational
factor to overcome barriers and difficulties that other minority students face.
Health Beliefs and Practices Among Black Africans
Health beliefs and practices have the ability to influence how an individual learns,
participates, and performs in the nursing classroom. There is a significant body of
literature related to health beliefs and practices among black African immigrants. The
general black African immigrant population arrives in the United States with superior
health compared to African American U.S. citizens and immigrants from all other
countries (Venters & Gany, 2009). This health status is in sharp contrast to black African
immigrants arriving as refugees.
19
Refugees often enter the country with poor physical health. Common disparities
include inadequate vaccinations, infectious diseases, nutritional deficiency, and poor
dental health (Palinkas et al., 2003; Tiong et al., 2003; Vaughn & Holloway, 2010).
Refugees fleeing from countries of war often report experiencing severe trauma and
violence that results in a number of mental and psychiatric disorders, including
depression and post-traumatic stress disorder (Neuner, Schauer, Klaschik, Karunakara, &
Elbert, 2004; Palinkas et al., 2003).
Although refugees differ from the general immigrant population in terms of their
physical and mental health, health beliefs appear to be congruent between the two groups.
Health beliefs regarding diet, exercise, immunizations, and the avoidance of high-risk
behaviors, such as drug use and smoking, are consistent with U.S. health promotion
guidelines (Carroll et al., 2007; Vaughn & Holloway, 2010). The literature presented a
different picture concerning beliefs surrounding the cause of illness, access to care,
knowledge of screening services, and relationships with healthcare providers.
Both black African immigrants and refugees take a holistic approach to health,
and medicine is viewed as a centered approach encompassing the context of their daily
lives, including relationships, productivity, self, and religion (Pavlish, Noor, & Brandt,
2010). This view differs significantly from the Western view of health as an absence
from illness. Religion plays a significant role in the health of both black African
immigrants and refugees, and, as such, illness can be viewed as a conflict between good
and evil (Adepoju, 2012; Vaughn & Holloway, 2010). This view may conflict with the
traditional biological view of Western medicine.
20
Although willing to access healthcare services within the United States, black
immigrants and refugees are more likely to access emergency healthcare services and
expect a diagnosis and cure for their symptoms (Carroll et al., 2007; Pavlish et al., 2010).
Study participants often voiced frustration and lack of trust when sent away without a
prescription or clear explanation of symptoms (Adepoju, 2012; Pavlish et al., 2010;
Vaughn & Holloway, 2010). Adepoju (2012) found that traditional medicine and prayer
often accompany or replace Western medicine when a diagnosis or cure is not offered. In
another sense, while black African immigrants and refugees are knowledgeable about
general health promotion principles, they have little knowledge of preventative healthcare
services or screening practices, such annual physicals and cancer screening (Carroll et al.,
2007; Palinkas et al., 2003; Vaughn & Holloway, 2010).
Black African immigrants and refugees value relationships within their families,
communities, and healthcare system. Vaughn and Holloway (2010) studied the health
beliefs and practices of 10 West African parents and concluded that a welcoming and
friendly environment was paramount in participants’ willingness to access healthcare
services. Black African immigrants and refugees expect providers to remember
interactions and form personal relationships (Pavlish et al., 2010; Simmelink, Lightfoot,
Dube, & Blevins, 2013). Finally, black African immigrants and refugees often turn to
family, friends, and community leaders for support in problem-solving and social–
emotional support (Vaughn & Holloway, 2010).
The literature presented has several implications for nursing education. There is a
need to recognize black African immigrants and refugees as a unique population with
needs and beliefs different from U.S.-born African Americans. A strong research base
21
indicates that black African immigrants experience superior health and would have little
trouble understanding U.S. preventative health principles within nursing education and
practice. Disparities evident within the refugee population can be contributed to
circumstance, as the literature has demonstrated that black African refugees have beliefs
and understanding consistent with the general black African immigrant population.
Rather, it is their circumstance of war and environment that results in poor health. Due to
their strong religious beliefs and ties with traditional medicine, black African immigrants
and refugees may have difficulty subscribing to the Western model of illness
management and biological causes. Finally, because black African immigrants and
refugees value relationships with their healthcare providers, family, and friends, it is
likely that they will expect the same from educational environments. Students who do not
feel a connection to or build a relationship with faculty may struggle within nursing
education programs. There are currently no studies that discuss the health behaviors of
black African immigrants and refugees in connection to the nursing practice, indicating
that more knowledge in this area is needed.
Nursing Practice Within the Black African Immigrant Population
When immigrants arrive within the United States, they bring with them values,
beliefs, and experiences from their native lands. How black African immigrants view and
interact with the profession of nursing within their countries of origin is likely to impact
their motivation and drive to enroll and complete their nursing education within the
United States. Very little information exists relating to nursing practices within sub-
Saharan countries. Only one research article was found to relate to the subject. Van der
Doef, Mbazzi, and Verhoeven (2011) used a cross-sectional descriptive design to explore
22
job conditions, job satisfaction, somatic complaints, and burnout among 309 female East
African nurses. Van der Doef et al. (2012) concluded that emotional exhaustion and
burnout was high among study participants. In addition, participants related poor working
conditions to problems with staffing, high workloads, inadequate equipment, and
generally poor facilities. Despite these obstacles, participants identified high levels of
satisfaction and pride within their profession and valued their positions as equal members
of the healthcare team.
The results of the study conducted by van der Doef et al. (2012) indicated that,
although nurses from East Africa experienced poor working conditions, high rates of
burnout, and emotional exhaustion, they viewed themselves as respected members of a
profession and displayed high levels of personal satisfaction. This finding indicates that
nursing is a valued profession within East Africa, and immigrants from that country are
likely to share that belief. However, these interpretations should be made with extreme
caution. The body of information related to nursing practices within sub-Saharan Africa
is limited and not representative of the entire sub-Saharan nursing population.
Additionally, information related to the use of nursing theory and models within sub-
Saharan Africa would be helpful in determining not only the focus of nursing care within
this area, but also beliefs surrounding the role and responsibilities of the nurse.
Understanding how black African immigrants have experienced nursing in their
homelands may provide valuable information regarding their motivation and desire to
become nurses within the United States.
23
Chapter Summary
The purpose of this study is to understand how black African immigrant nurses
experience nursing education within the United States. This topic was found to be
significantly under-studied. Of those studies identified, sample sizes were small, mixed,
and not representative of the sub-Saharan population. Furthermore, the literature revealed
that black African immigrants are a unique population with needs, cultures, and practices
that differ from U.S.-born African Americans, and, as such, they have unique needs that
may not be addressed by current educational practices. Although black African
immigrants are currently the fastest growing immigrant population within the United
States, nurses of the same ethnic background are under-represented in the current U.S.
nursing workforce demographics. More information is needed to understand how best to
address the unique needs of this population in relation to nursing education pedagogy.
24
CHAPTER III
METHOD OF INQUIRY GENERAL
Phenomenology is the method of inquiry used to conduct this study. This method
was chosen because little is known about the experiences of black African nursing
students. According to Streubert and Carpenter (2011), phenomenology is used to
describe a particular phenomenon of interest from a holistic perspective. The historian
Herbert Spiegelberg (1975) identified phenomenology as a philosophical movement that
describes phenomena as consciously experienced without influence of preconceived
theories and understanding. The essence of phenomenology is to form an understanding
of a population, event, or phenomenon, and is inductive. Therefore, as a method of
qualitative study, phenomenology is classified under the interpretivism paradigm that
guides the work of social scientists and is well suited for developing the science of
nursing and nursing education (Glesne, 2011). Because little is known about the
experience of black African nurses educated in the United States, phenomenology would
be an ideal method for identifying a true meaning.
True meaning is necessary in order to identify strategies that will guide culturally
competent curriculum development to prepare the black African population for successful
entry into practice. Diekelmann (1988) defined curriculum as the lived experience of
students, teachers, and clinicians as they work together to understand how best to prepare
students to enter the nursing practice. The purpose of this study is to gain an
understanding of how black African nurses experience nursing education within the
United States. It is through this understanding that curricular and administrative changes
may be proposed to improve the retention and success of this population.
25
Historical Foundations of Phenomenology
Preparatory Phase
The scientific rigor of phenomenology was studied and tested in the early 19th century
by Franz Brentano and Carl Stumpf (Spiegelberg, 1975). Intentionality was a primary
focus of their work and is defined by Streubert and Carpenter (2011) as “the conscious is
always conscious of itself” (p. 75). In this preparatory phase, Brentano and Stumpf laid
the foundation for phenomenological inquiry by explaining that one cannot form opinions
and conclusions about a phenomenon until he or she perceives the phenomenon
externally (Streubert & Carpenter, 2011). For example, a sound is often described as
loud, quiet, harsh, or melodic. However, one cannot draw those conclusions without first
hearing the sound. In terms of the topic under investigation, assumptions about the
retention of African immigrant nursing students cannot be made unless the experience
from the perspective of the student are understood.
German Phase
Edmund Husserl and Martin Heidegger led a second phase of phenomenological
development that spanned from the mid-1800s through the 1970s. The focus of this phase
was on development essences, intuiting, and phenomenological reduction (Streubert &
Carpenter, 2011). Essences define a phenomenon and are described as the basic units of
understanding of a phenomenon (Streubert & Carpenter, 2011). Intuiting describes the
process by which the researcher interprets and varies data to demonstrate the meaning of
a phenomenon. Finally, true phenomenological reduction requires that the research return
to its original sense of awareness regarding the phenomenon under investigation. The
literature review presented in Chapter II returned very few results related to the African
26
refugee population as it relates to nursing students. However, there is a significant body
of knowledge relating the challenges and experiences of African refugees. Applied to the
topic under investigation, it is important to bracket this information to avoid transferring
what is known about African refugees onto study participants. Only then can the
researcher arrive at a pure description of the participants’ experiences related to nursing
education.
French Phase
The final phase of phenomenological development occurred from the late 1800s
through 1980 and is referred to as the French Phase. According to Streubert and
Carpenter (2011), the focus of this final phase is on “embodiment and being-in-the-
world” (p. 77) in which perceptions are based on original phenomenon. By gaining
insight into African refugee nurses’ experience with nursing education, interventions can
be based on conscious experience rather than preconceived judgments.
Researching Lived Experience by Max van Manen
Max van Manen (1990) is credited with identifying a contemporary approach to
hermeneutic phenomenology. Hermeneutic phenomenology, also referred to as
interpretive phenomenology, is unique because it does not require the researcher to
bracket preconceptions or theories during the research process (Streubert & Carpenter,
2011). Therefore, dissertation requirements and this researcher’s experience with the
chosen population make this method of phenomenology a logical choice. Van Manen
(1990) described hermeneutic phenomenology as action sensitive and advocates the use
of the method to improve pedagogy. The clarity of the six distinct steps that van Manen
identified make it a popular method in the disciplines of nursing, education, clinical
27
psychology, and law (Earle, 2010). These six steps form a framework for the study of
African-born refugee nurses’ experience of nursing education and include the following:
1. turning to a phenomenon which seriously interests us and commits us to the
world,
2. investigating experience as it is lived rather than as it is conceptualized,
3. reflecting on the essential themes that characterize the phenomenon,
4. describing the phenomenon through the art of writing and rewriting,
5. maintaining a strong and oriented pedagogical relation to the phenomenon, and
6. balancing the research context by considering parts and whole (van Manen, 1990,
p. 30).
Phenomenological Activities Related to This Study
Max van Manen (1990) identified the first step in hermeneutic phenomenology as
turning to a phenomenon that seriously interests us and commits us to the world. Within
this step, the researcher identifies a concern of human existence and attempts to
understand, or make sense of, this concern. My interest in the subject of black African-
born nursing students began as a nursing faculty in an undergraduate nursing program.
Approximately two-to-four African-born students were admitted to the nursing program
each semester. However, after only one semester of instruction, it was obvious that these
students struggled in ways different from traditional students born in the United States.
Discussions with colleagues revealed themes relating to language barriers, social
isolation, and cultural barriers.
When arriving to the classroom, students from black African cultures often sat
together, isolated from other American-born students. They rarely attempted to socialize
28
with other students. Cultural barriers related to authority, nursing concepts, and family
responsibilities also provided a challenging atmosphere. For example, a particular student
that was otherwise succeeding in a course was challenged by mental health content.
During a meeting, the student revealed that no concept of mental illness or mental health
existed within her culture. Other cultural barriers that existed included the reluctance to
ask questions because of the need to show respect to faculty in positions of higher
authority and an inability to set aside appropriate time for study due to role expectations
within the family unit.
Although differences were unique to each student, a common difference in
attrition rates prevailed. Students that were African-born had a significantly higher
attrition rate than American-born students. According to van Manen (1990), the
phenomenological researcher must commit to making sense of relevant concerns. In this
case, the concern is an increase in attrition rates for African-born nursing students.
Through the holistic approach of hermeneutic phenomenology, this researcher hopes to
uncover meaning that might be otherwise overlooked or considered insignificant when
addressing attrition.
The second research activity, investigating the experience as it is lived, is
described by van Manen (1990) as “becoming full of the world, full of experience” (p.
32). In this stage, the researcher becomes immersed in the phenomenon of interest so that
true meaning can be revealed (Earle, 2010). In phenomenological research, data is
gathered through interviews, writing, and observation (Earle, 2010). Conducting
interviews with black African-born nurses who completed their nursing education in the
29
United States allows the researcher to gain rich descriptions and a deeper understanding
of the participants’ full experience.
The third research activity, reflecting on essential themes, uncovers the essence of
the experience and makes the obscure clear (van Manen, 1990). In this activity,
interviews are analyzed for common themes that provide a rich description of the
experience of black African-born nursing students. Only themes that are necessary for
demonstrating true meaning should be included in the final description. Once these
critical themes are identified, they must then be illuminated by specific phrases from the
data that capture meaning (Earle, 2010).
The fourth research activity, the art of writing and rewriting, is concerned with
translating the phenomenon into writing. As van Manen (1990) described, the purpose of
writing is to show the phenomenon exactly as it shows itself. More specifically, writing
and re-writing “makes what is external internal” (Earle, 2010, p. 210). During the fourth
activity, this researcher attempts to put the voices of the participants into writing.
The fifth activity, maintaining a strong and oriented relation to the phenomenon,
is a dedication to remain steadfast in the quest to understand the true meaning of the
phenomenon under investigation. Van Manen (1990) warned that the tedious nature of
phenomenological research can lure researchers into reverting to preconceived notions or
“wishy-washy” theories (p. 33). As described previously, this researcher has had personal
experience with the phenomenon under study and has developed perceived ideas relating
to barriers faced by black African-born students. It will be particularly important that
these biases are separated so that the researcher may approach participants’ experiences
with an open mind.
30
The sixth and final activity, balancing the research context by considering parts
and whole, requires the researcher to keep the focus on the big picture and ensure that the
study remains sound in methodology. Smaller parts should be continuously weighed
against the whole to avoid becoming buried in text (van Manen, 1990). Within this study,
this researcher needed to periodically “step back” to determine the effect of the study on
the participants, institution, and researcher, and to achieve a deep understanding of the
phenomenon of interest (DeBoor, 2010).
Participant Selection
Hermeneutic phenomenology is concerned with information-rich interviews and
cases (Cohen, Kahn, & Steeves, 2000). Therefore, it will be important to select
participants who have knowledge of the phenomenon and who are able to describe their
experiences fully. One way to accomplish this is through purposive sampling. Purposive
sampling is the most commonly used method of sampling in phenomenological research
and provides a means of identifying participants that are most appropriate in describing
their experiences related to the purpose of the study (Streubert & Carpenter, 2011).
Because of the limited number of black African nurses practicing in the United States,
snowballing is also used as a sampling method. Snowballing is an important means of
identifying participants when populations are difficult to locate (Streubert & Carpenter,
2011). Sampling continues until saturation is reached; therefore, it is impossible to dictate
the required number of participants until the researcher is immersed in interviews (Patton,
2002; Streubert & Carpenter, 2011). Specific criteria and the method of purposeful
selection are discussed further in Chapter IV.
31
Data Generation and Analysis Procedures
Semi-structured and structured interviews are most commonly used for data
generation in phenomenological studies (Balls, 2009). Using van Manen (1990) as a
framework, hermeneutic interviewing starting with the question “what is it like?” is a
helpful way to develop a conversation with a participant about the meaning of his or her
experience (p. 42). Having a rigid or structured interview process could interfere with
participants’ ability to tell their stories fully. Therefore, probing questions are used only
after the initial question. Interview questions are provided in Appendix C. Van Manen
(1990) suggested that using probing questions such as “can you share a specific instance
or situation?” and “how did you feel in that situation?” can be helpful in developing a
deeper understanding of the phenomenon and participant experience (p. 42).
In order for participants to feel at ease with sharing their experiences freely, trust
must be developed between the interviewer and interviewee (Patton, 2002). The literature
demonstrates that issues of trust can develop as a result of cultural differences. Therefore,
it was essential for this researcher to first develop a trusting relationship with participants
so that they might feel safe to disclose and explain their experiences fully. In addition, the
literature has demonstrated the importance of personal connection within the black
African immigrant population. Therefore, the interviewer must create a welcoming and
friendly environment. Merriam-Webster (2012) defines trust as the “firm belief or
confidence in the honesty, integrity, reliability, justice, etc. of another person or thing.”
Translating this definition into the interview process, a trusting relationship can be
established through full disclosure of the research process, obtaining consent for tape-
recording and sharing of information, and maintaining confidentiality.
32
Displaying cultural competence in working with diverse populations is important
in establishing a trusting relationship (Pacquiao, 2007). Establishing rapport can help to
facilitate sharing. “Fitting in” is a facet of interviewing that is necessary in order to build
a relationship and rapport with participants (Glesne, 2011, p. 141). It was important for
this researcher to understand customs and beliefs of African-born nurses to earn
participants’ respect. This researcher needed to be mindful of dress, language, and
gestures to avoid offending or intimidating participants. An interpreter was offered to
participants that feel more comfortable discussing their experiences within their native
language.
Data was gathered through the use of one-hour face-to-face semi-structured
interviews. Fatigue and diminished return often set in for both participants and researcher
in interviews that last longer than one hour (Glesne, 2011). Participants were provided
with the opportunity to select the time and place for interviewing, provided that the
chosen site was private and conducive to interviewing. Allowing the participant to choose
a location demonstrates a respect for privacy and human dignity. It allows the participants
autonomy in the interviewing process and assists in the development of a trusting
relationship that supports participants in freely sharing their experiences. Internet-based
or phone interviews may occur after face-to-face options have been exhausted in follow-
up interviews when further clarification is needed. Open-ended questioning, recording,
and transcriptions improve the reliability of data (Streubert & Carpenter, 2011).
Therefore, sessions were recorded using a digital recorder and immediately transcribed.
Interview questions were prepared in advance and included demographic information for
the purpose of describing a participant’s characteristics.
33
Colaizzi’s (1978) seven-step method of data-analysis is often used to
operationalize van Manen’s (1990) approach and was used to interpret findings (Streubert
& Carpenter, 2011). These steps include the following: (1) extraction of phrases or
sentences pertaining to the experience; (2) transforming phrases into own words,
resulting in a list of “meaning” or “significant” statements; (3) clustering of individual
themes to produce further reduction; (4) production of hypothetical “exhaustive” lists; (5)
moving back and forth between meaning statements and successive hypothetical lists
until themes are accurately reflected in the clusters; (6) describing the essential structure;
and (7) returning descriptions to subjects and revising descriptions if necessary.
Extracting Significant Statements
The first step in Colaizzi’s (1978) seven-step method is to familiarize oneself with
the data. Transcripts are read and re-read several times to gain a sense of the whole and
become immersed in the data. It is through this immersion that individual essences are
revealed (van Manen, 1990).
Formulating Meanings of Significant Statements
Step two in the analysis of phenomenological data, according to Colaizzi (1978),
is to extract specific phrases and statements from the transcript that are relevant to the
phenomenon of interest. Statements are initially highlighted and then compiled within a
separate database noting transcript name, page, and line number (Shosha, 2012; Streubert
and Carpenter, 2011).
Clustering of Individual Themes
In step three of Colaizzi’s (1978) method, more general statements or themes are
formulated for each statement taken from the text. The researcher transforms what is said
34
into the meaning of the lived-experience of participants. These transformations “discover
and illuminate those meanings hidden in the various contexts and horizons of the
investigated phenomenon” (Colaizzi, 1978, p. 59).
Organizing Formulated Meanings Into Clusters of Themes
Colaizzi (1978) described step four of data analysis as inclusive of two activities:
(1) arranging formulated meanings into clusters of themes, and (2) identifying
discrepancies among them. He cautioned the researcher to keep an open mind to avoid
dismissing statements that are “logically inexplicable” because the statements provided
by participants are real and valid experiences (Colaizzi, 1978, p. 61).
Exhaustively Describing the Investigated Phenomenon
During step five of analysis, Colaizzi (1978) instructed the researcher to use all
themes identified into an exhaustive description of the phenomenon. Holloway and
Wheeler (2006) advised researchers to combine all themes, clusters, and formulated
meanings to create an overall structure that is inclusive of all of the elements of the
experience.
Describing the Fundamental Structure of the Phenomenon
In step six of Colaizzi’s (1978) process of analysis, the researcher reduces the
length of the exhaustive list to provide an explicit statement of the phenomenon reflecting
an essential structure.
Validating Findings With the Participants
Step seven, the final step in Colaizzi’s (1978) process of analysis, requires that the
researcher return to the participants to validate the interpretations and themes identified.
Holloway and Wheeler (2006) suggested that researchers share exhaustive lists and
35
descriptions with participants versus the essential structure because it may be more
identifiable to participants. Additional comments are solicited from participants and
incorporated into the overall structure (Colaizzi, 1978).
Ensuring Trustworthiness
While quantitative research relies heavily on the concepts of reliability and
validity to demonstrate its worth, the naturalistic qualities of qualitative research require a
different approach. Reliability and validity are often re-envisioned as trustworthiness and
accuracy in qualitative study. Lincoln and Guba (1985) proposed four components of
trustworthiness that ensure rigor of qualitative studies. These four components
(credibility, transferability, dependability, and confirmability) are described in the
following paragraphs.
Credibility
Credibility is otherwise known as truth value and is the counterpart to internal
validity in quantitative research (Guba, 1981). Member checking, negative case analysis,
and triangulation are three methods for ensuring the credibility of a qualitative study
(Lincoln & Guba, 1985). In conducting member checking, researchers return to
participants to validate that accuracy of essential themes and descriptions (Creswell,
2006). Negative case analysis refers to discussing elements of the phenomenon that
appear to conflict with patterns or data that is emerging (Creswell, 2006). Finally,
triangulation involves the use of multiple sources, perspectives, or theories to maintain a
holistic perspective (Creswell, 2006).
36
Transferability
Transferability is the qualitative counterpart to external validity utilized within
quantitative research. Lincoln and Guba (1985) defined transferability as the ability to
apply findings in different contexts, settings, and groups. The use of thick description is
one way to ensure the transferability of findings. Thick descriptions refers to describing
in such detail that one could transfer them for use within different contexts (Lincoln &
Guba, 1985).
Dependability
Dependability is defined as the ability to demonstrate that findings are consistent
and could be duplicated (Lincoln & Guba, 1985). In the case of phenomenological
studies, cases are unique and unlikely to be replicated due to their humanistic nature,
albeit the phenomenological researcher strives to reveal meaning that would be similar to
participants in comparable contexts. Lincoln and Guba (1985) identified the technique of
external auditing as a technique to demonstrate dependability. An external audit involves
soliciting an outside person to examine the research process and products of research
(Creswell, 2006). An audit trail includes a record of the research process, data, and
products.
Confirmability
Lincoln and Guba (1985) defined confirmability in terms of neutrality or the
degree to which findings are “a function solely of the conditions of inquiry and not of the
biases, motivations, interests, or perspectives of the inquirer” (p. 376). Methods for
establishing confirmability include triangulation, confirmability audit, and audit trail,
which were discussed previously.
37
Chapter Summary
Chapter III provided an overview of the method of phenomenology and its
applicability to the study of the lived experienced of black African nursing students. Van
Manen’s (1990) six-step method for hermeneutic phenomenology was described. A
description of Colaizzi’s (1978) seven-step process was presented as a framework for the
analysis of data. Finally, steps for ensuring trustworthiness in phenomenological research
were discussed using strategies presented by Lincoln and Guba (1985).
38
CHAPTER IV
METHOD OF INQUIRY APPLIED
Participant Recruitment and Selection
Hermeneutic phenomenology is concerned with information-rich interviews and
cases (Cohen et al., 2000). For this reason, it was important to select black African
immigrant nurses who were able to fully describe their experience as nursing students.
Purposive sampling is the most commonly used method of sampling in
phenomenological research (Streubert & Carpenter, 2011). As a result, purposive
sampling was used to recruit black African immigrant nurses working the Midwest
United States. According to Remington (2008), the upper Midwest is home to one of the
largest populations of black African immigrants in the country and provided additional
incentive to focus on this area for recruitment.
Phenomenology requires that data collection continues until saturation is obtained
(Streubert & Carpenter, 2011). Consequently, it was impossible to dictate the required
number of participants until the researcher was immersed in interviews. A goal of 10–12
participants was optimal because phenomenologist often rely on samples of 10 or fewer
(Polit, Beck, & Owen, 2008). Three participants responded to initial recruitment efforts.
According to Glesne (2011), snowballing can be helpful in identifying hard-to-locate
populations and is often used when other methods have been exhausted. Because the
small and isolated nature of the population under investigation made identification
difficult, snowball sampling was used as an additional method for recruitment. Six
additional participants were identified through snowballing. In the end, a total of nine
participants were identified.
39
Black Africans emigrate from sub-Saharan regions of the continent. Therefore,
the first inclusion criterion was that participants had emigrated from a sub-Saharan
African country of origin (Capp et al., 2011). Immigrants from the southern region of
Africa are predominately white, well educated, and are likely to have English as a
primary language. Therefore, participants originating from a country in the southern
region of Africa were excluded.
This study aimed to understand the nursing education experience of black African
nurses educated in the United States. Hence, the second inclusion criterion required that
participants had graduated from a United States–based undergraduate registered nurse
program. Placing no time limit on the years since graduation provided enrichment of the
data because participants’ recall and insight into their experiences had likely changed
over years of assimilation and practice.
The final inclusion criterion for sample selection was current employment as a
registered nurse. Employment status was important in demonstrating that participants had
not only been successful in graduating from a program of nursing, but had also been
successful in passing the NCLEX licensure exam and integrating into the profession.
Furthermore, it was assumed that employed nurses were able to draw meaningful
connections between nursing education and their nursing practice.
Participants were not excluded based on age or sex. Refugees as well as
immigrants from sub-Saharan Africa were included in the study. Black African
immigrants are generally well educated. However, African refugees often have poor
English skills, are poorly educated, and are more likely to live in poverty (Capp et al.,
40
2011). In addition, refugees are likely to have experienced significant physical and
mental health issues as a result of conditions in their homeland, and are likely to have
experienced additional hardships not encountered by the general black African immigrant
population (Martin & Yankay, 2012; Palinkas et al., 2003). Therefore, inclusion of black
African refugees was thought to increase the depth and richness of data and aid in the
trasnferrability of findings.
Gaining Access
Protection of Human Subjects
Institutional Review Board (IRB) approval for this study was sought through the
University of Nevada–Las Vegas (UNLV), (See Appendix G). The risk of unintentional
discrimination and potential vulnerability of the population involved in the study made
the selection of participants the most risk-prone ethical issue. Deontological theory holds
that researchers “must do good things because we have a duty to” (Levine, 2010, p.
xxxii). The American Nurses Association (2008) Guide to the Code of Ethics for Nurses
uses the “duty” in relation to the profession’s responsibility to protect research
participants. As stated in Principle 3.2 of the Code of Ethics for Nurses (American Nurses
Association, 2008), self-determination is an essential component in our duty to protect
research participants from harm. It was imperative to obtain informed consent from
participants. Obtaining informed consent included ensuring that participants received the
necessary information to make an informed decision regarding participation in the study,
that they understood their ability to terminate their participation in the study without
penalty, and that they were aware of the ways in which data would be used and managed
(American Nurses Association, 2008).
41
Information obtained through this study remained confidential. Participants were
assigned a pseudonym to protect their identities. Pseudonyms were utilized in all written
aspects of the research including questionnaires, transcriptions, and field notes.
Participant contact information and pseudonyms were kept in a locked location by the
researcher. The researcher followed IRB protocols for the storage of all information and
data gained through the research. Following the completion of the study, all records are
stored in a locked facility at UNLV for three years. After the three-year time frame, the
information will be gathered and destroyed.
Recruitment
Recruitment flyers were distributed via e-mail to a number of organizations.
Organizations that received flyers for disbursement included the Nigerian and Somalian
Nurses Associations, Lutheran social services, Catholic charities, and World Relief.
According to Remington (2008), these organizations serve as common entry points for
settlement, and are gathering areas for the target population within the upper Midwest
area. Despite repeated efforts, no organization responded to requests to distribute flyers,
and no participants were identified through these means. Directors of schools of nursing
who had contact with African students aided in the recruitment and identification of
possible participants by contacting alumni to inform them of the study. Interested nurses
were asked to contact the researcher via telephone, e-mail, or text to obtain contact
information and general information relating to the study. Because the study required
participants to engage in multiple interviews, a gift-card incentive was used to attract and
retain participants. A $10.00 gift card was given at the conclusion of the first interview,
and a $15 gift card was mailed to participants following the second interview.
42
During the initial contact, the researcher informed participants of confidentiality
procedures and ensured that the participant met all inclusion criteria. Once eligibility was
confirmed, a face-to-face meeting was arranged for the formal interview. During this
face-to-face meeting, the participant was informed of the structure of the interviews.
Consent was obtained for the audio-taping of interviews, transcription of interviews, and
the handling and reporting of data. Any participant questions related to the study were
addressed.
Consent
Informed consent was obtained through the form included in Appendix E. The
form is in compliance with the UNLV IRB. Through informed consent, participants were
notified of their right to refuse participation, or to withdraw from the study at any time
without penalty. Benefits and risks of the study were detailed, and statements concerning
the confidentiality of data were explicit. All participants that met the inclusion criteria for
this study completed the consent process prior to beginning the first interview.
Data Generation and Analysis Procedures
Data Generation
As discussed in Chapter III, issues of trust can result from cultural differences.
Therefore, it was essential for this researcher to first develop a trusting relationship with
participants so that they felt safe to fully disclose and explain their experiences. In
addition, the literature demonstrated the importance of personal connection within the
black African immigrant population. Therefore, the interviewer created a welcoming and
friendly environment by conducting the interview at a time and location that was chosen
by and convenient for the participant. A trusting relationship was established through full
43
disclosure of the research process, obtaining consent for tape recording and sharing of
information, and maintaining confidentiality.
Displaying cultural competence in working with diverse populations is important
in establishing a trusting relationship (Pacquiao, 2007). This researcher established
rapport by being mindful of dress, language, and gestures in order to avoid offending or
intimidating participants. All participants were fluent in the English language and
therefore did not require an interpreter.
Data was initially gathered through the use of one-hour face-to-face semi-
structured interviews. The one-hour time frame was chosen because fatigue and
diminished return often sets in for both participants and researcher in interviews that last
longer than one hour (Glesne, 2011). Participants were provided with the opportunity to
select the time and place for interviewing, provided that the chosen site was private and
conducive to interviewing. Allowing the participant to choose a location demonstrated a
respect for privacy and human dignity. It allowed the participant autonomy in the
interviewing process and assisted in the development of a trusting relationship that
supported the participant in freely sharing his or her experiences.
Open-ended questioning, recording, and transcription improve the reliability of
data (Streubert & Carpenter, 2011). Therefore, sessions were recorded using a digital
recorder and immediately transcribed using computer software. Interview questions were
prepared in advance (see Appendix C). Demographic information (see Appendix F) was
gathered for the purpose of identifying participant characteristics and providing context
for experiences. Field notes were utilized to document non-verbal cues and aspects of the
44
interview that could not be provided through recording. Field notes also provided an audit
trail for ensuring trustworthiness.
Data Analysis
Data was analyzed using Colaizzi’s (1978) seven-step method of
phenomenological analysis and included the following activities:
Reading all descriptions. The researcher read through the interviews in their
entirety in order to get a feel for the whole. During this stage, any thoughts, or feelings as
a result of the researcher’s previous experience with black African students was
bracketed alongside the transcript within NVivo. Bracketing allowed the researcher to
remain true to the participants’ experiences.
45
Extracting significant statements. After the initial reading, the researcher
returned to the data to extract significant statements that related directly to black African
nurses’ experiences with nursing education. These statements were assigned nodes within
NVivo and coded based on their transcript, page, and line numbers.
Formulation of meanings. Meanings were formulated from the significant
words, statements, and phrases. A single table was created within NVivo to identify the
original statement along with the formulated meanings. The table enabled the committee
and experts to reflect on the meanings and assist in auditing the rigor and quality of the
research as requested.
Organizing formulated meanings into clusters of themes. Nvivo software
aided in aggregating the formulated meanings identified in step three into clusters of
themes. These clusters were compared to the original transcripts for validation.
Discrepancies and contraindications were identified and outliers were carefully
considered.
Exhaustively describing the investigated phenomenon. The researcher
integrated major themes and sub-themes into an exhaustive narrative description of the
lived experience of black African nurses educated within the United States.
Describing the fundamental structure of the phenomenon. The exhaustive
description was reduced to an essential structure by removing redundant or misused
descriptions.
46
Validating findings with participants. Participants were provided with
transcripts and exhaustive description of themes via e-mail contact. Participants were
provided one week to review the material. Additional feedback or insight provided by
participants was incorporated into the essential structure.
Ensuring Trustworthiness and Authenticity
Credibility
Lincoln and Guba (1985) identified member checking, triangulation, and negative
case analysis as strategies that are effective in demonstrating the credibility of qualitative
research. To engage in member-checking, the researcher returned to participants
following the identification of formulated meanings and extraction of themes and
phrases. During the second contact, the researcher asked participants for validation and
additional insight to be incorporated into the essential structure. Participants were e-
mailed a summary of the findings along with the model (see Figure 7).
The researcher engaged in negative case analysis by asking participants to
identify and discuss unsuccessful experiences during their nursing education. Questions
such as “describe a time when you were unsuccessful?” or “tell me about a time when
you felt particularly discouraged in your nursing education” were used for this purpose.
Finally, triangulation was accomplished through the careful selection of participants from
varying educational levels, ages, countries of origin, linguistic development, and program
sites.
Transferability
Thick descriptions of the phenomenon were necessary in order to ensure the
transferability of findings to similar groups and contexts (Lincoln & Guba, 1985).
47
Purposive sampling aided in the selection of participants who were able to fully describe
their experience. This researcher remained diligent in the inclusion of detailed
descriptions in the written analysis. Finally, field notes that include non-verbal and
environmental observations were recorded.
Dependability
Lincoln and Guba (1985) identified the technique of external auditing as a
technique to demonstrate dependability. Field notes were utilized to document the
process of interviewing and to record aspects of the interview that could not be garnered
from the recordings. In addition, tables displaying the original data, meaning
transformations, and the extraction of themes documented the process of data analysis.
The researcher engaged in a confirmability audit with the faculty chair and dissertation
committee throughout the research study.
Confirmability
Methods for establishing confirmability include triangulation, confirmability
audit, and audit trail (Lincoln & Guba, 1985). The researcher utilized these processes as
previously discussed in this chapter to ensure the confirmability of findings.
Chapter Summary
This chapter applied the principles of van Manen’s (1990) phenomenological
approach to the study of black African nurses educated in the United States. Colaizzi’s
(1978) process for data analysis was applied to the phenomenon of interest. Finally, the
work of Lincoln and Guba (1985) was applied to demonstrate the trustworthiness of
findings.
48
CHAPTER V
FINDINGS
The question and purpose guiding this study is: How do black African nurses
experience nursing education within the United States? Phenomenology makes what is
internal, external, and allows one to understand and communicate the true essence of the
phenomenon in order to change practice (van Manen, 1990). The nine participants’
stories that follow provide the unified voice that communicates this essence.
Description of Participants
A total of nine African nurses participated in this study. Five of the participants
were male and four of the participants were female. Countries of origin included Sierra-
Leone, Kenya, Liberia, Eritrea, and Ethiopia. Participants were of varying educational
backgrounds. Six participants received associate degrees, and three participants received
baccalaureate degrees as their pre-licensure preparation. Four participants reported
holding previously attained degrees, three of which were in healthcare. Most participants
were in the country less than two years before beginning their nursing education. Only
two participants were in the country longer than two years—three and four years,
respectively. Individual participant profiles are located in Appendix G.
Data Collection
The nine participant interviews were conducted between November 2013 and
January 2014. One participant was known to the researcher as a former student. Four
students were referred to the researcher by a colleague who conducted a research study
with minority students. The remaining three participants were identified through
snowballing.
49
Initial interviews were conducted face to face at a time and location that was
chosen by the participant. Five interviews were conducted in study rooms at local public
libraries. The remaining three interviews were conducted at cafés close to the
participants’ employers and residences because private conference rooms were not
available at the time and day that the participant chose. In all cases, the researcher sat
across a table from the participant with a digital recorder placed centrally. Wait staff and
library personnel were asked not to disturb the interview process, and both participant
and researcher turned off cell phones.
Each interview began by presenting the participant with a $10.00 gift card and by
engaging the participant in casual dialogue in an effort to establish rapport. Next, the
researcher obtained informed consent using the approved form. The researcher read each
section of the informed consent form to the participant and answered any questions that
the participant had. The participant was instructed of the interview process and reminded
of his or her ability to withdraw from the study. Once the informed consent was signed,
the researcher provided the participant with a copy and asked the participant to complete
the demographic questionnaire. The questionnaire and its purpose were explained.
Participants were allowed to complete the questionnaire while the researcher remained
present to answer any questions.
Once all required paperwork was completed, the recorder was turned on. The
researcher reminded participants that they could refuse to answer any or all questions.
Participants were asked one last time if they had any further questions. The interview
began with an open-ended question: “Tell me about your nursing program experience.”
Prompts were provided throughout the interview time to encourage discussion (see
50
Appendix C). Once all questions were answered and the participant was finished with his
or her thoughts, the researcher asked, “Is there anything else you would like to tell me
about your nursing education experience?” If the participant had nothing else to offer, the
researcher then turned off the recorder. If the participant disclosed additional information
while engaging in casual conversation following the interview, the recorder was turned
back on and the participant was asked to repeat his or her comments.
Follow-up meetings were conducted in February 2014 following the completion
of the initial interviews. These communications were performed through phone and e-
mail conversations, based on the availability of the participants. Participants were
provided a copy of the study findings and model and given one week to respond with
comments. Participants were also provided with the opportunity to add new information
or thoughts they had regarding their nursing education experience. All nine participants
who participated in the study completed the study. The following excerpts validate the
researcher’s findings:
I read the attached documents from your study and I must say you
captured the experiences and journey of most African students perfectly. It
truly represents our experiences in a very succinct manner. I couldn’t have
done it any better. It is true that determination and optimism is what drives
the African student to overcome any perceived barriers or limitation.
Thanks for allowing me to participate in this study. I hope this helps other
African nursing students in their journey to becoming a nurse. (Debra)
Thank you for including me in your research project. I read through the
article and it is a true representation of Africans’ view/journey of the US
education. There is nothing more I could think of or add. Good
luck. (Charlie)
I found your summarized findings interesting and they reflects the real
challenges immigrant students are facing. As an immigrant student and
with several friends with similar background, I have witnessed immigrant
students engage in self- discrimination and paying the price for that. I
51
believe that current and future immigrant students will learn a lot from
your paper. I am grateful for the opportunity! (John)
Data Analysis
The researcher transcribed each of the interviews within a Microsoft Word
document. Transcripts were uploaded into NVivo and coded through the assignment of
nodes. Data was then analyzed using Colaizzi’s seven-step method as outlined in chapter
four.
Essence, Themes, and Sub-Themes
Optimistic determination was identified as the overall essence of the participants’
experience. From this essence four themes emerged that exemplify black African nurses’
experience with nursing education in the United States. These themes included (1)
academics, (2) relationships, (3) competing demands, and (4) culture. Sub-themes were
identified within all four major themes. The essence and themes are presented in a model
depicting the lived experience of black African nurses educated within the United States
(see Figure 7). The outer circles of the model depict the four themes of academics,
relationships, competing demands, and culture. All four are interconnected and affect
each other. For example, programs with pedagogy that required interaction between
students influenced relationships. Relationships with faculty and peers influenced
academic performance. Competing demands such as the need to work and provide for
family influenced the time needed to develop supportive relationships, and the time
needed to focus on academic requirements. Culture was the fourth theme and plays a role
in how the participants perceived and interacted with academics, relationships, and
priorities. At the center of the model is the overarching essence of the participants’
experience optimistic determinism.
52
Essence: Optimistic Determination
Participants spoke of a number of barriers and challenges that they had to
overcome to be successful in their nursing programs. When asked, “What helped to
support you in your nursing education?” participants responded with statements of
optimistic determination. Merriam-Webster defines optimism as an inclination to put the
most favorable construction upon actions and events or to anticipate the best possible
outcome (“Optimism,” n.d.-a). Oxford Dictionaries defines optimism as hopefulness and
confidence about the future or the successful outcome of something (“Optimism,” n.d.-b).
Oxford Dictionaries defines determination as firmness of purpose; resoluteness
(“Determination,” n.d-a.). Merriam-Webster defines determination as a quality that
makes you continue trying to do or achieve something that is difficult; firm or fixed
Figure 7. Model Depicting the Lived Experience of Black African Nurses
Educated Within the United States
53
intention to achieve a desired end (“Determination, “ n.d.-b). Participants offered general
statements that demonstrated optimistic determination. The following excerpts exemplify
the positive thinking and determination that was at the heart of participants lived
experience.
So you have to have your guns ready to go. So I work extra hard and I
read extensively to be able to be successful. Yeah. (Charlie)
Yeah. And I want, like, a better life for my children, for my kids, so. And I
like challenges. And if, like, I decide to do one thing, like, I have to do it
no matter what. (Grace)
When you go to school, it is an investment. You invest your time. I don’t
blame anyone, because everyone has his or her own life. (Dan)
You have to dedicate yourself, forget everything, and then you have to
focus for the goal you intended to achieve. I think that’s the most
important. And then you see the impact; the more time you spend
studying, the more time you invest in your studying, and then the
management on your study schedule, you know, you see the impact. . . .
Just if you study, if you go prepared to the class and then during the
discussion and during the lecture, you more understand what the professor
is talking, what the discussion is about, and then you motivate yourself.
You feel then comfort, being prepared. (Dan)
You have to be a positive person. If you see negative things in your life,
you don’t achieve. I don’t know, that’s my experience. Okay, and then I
will find I will have a better life. I will have a better future. (Dan)
Some people, they complain, instead of working hard they complain as a
self-defense. (Dan)
There is a small impact, there is, but it’s not a major issue if you work
hard, if you have a plan, if you think of a good future, if you are a positive
person, there is no barrier to achieve the nursing program. That’s my
opinion. (Dan)
I mean, I felt like if there was something difficult for me, that just made it
challenging and I needed to overcome that. Because I was going to be a
nurse and nobody was going to stop me from being a nurse. (Debra)
54
You know, when I first applied for the nursing program, the nursing
advisor told me that this is a very complicated program, are you sure you
can do it? Are you going to take a loan and financial aid, and that would
be important for you to pay back and are you sure you make it? And I told
her, just give me the chance and I’m sure that you’re not going to ask me
this question every semester. (John)
You know, I was kind of discouraged at that time. But since I changed my
plan, how to read, which area to focus, I just tried to improve a lot. (John)
I kept reminding myself nothing is permanent, nothing is permanent.
(Emma)
So then we decided, and that was the day also I decided, I said, well, I will
give each student a second chance. (Katherine)
And my drive. And I realized where I came from that a lot of people
depend on me. And one thing I realized that I learned here the moment I
got into this country was if you want to be better off to care for yourself,
provide for your family, then you have to continue in education. And that
was my drive. I said I don’t want my kids to look at somebody on TV and
say this is their role model. I want them to look at me and say, my mom is
my role model. My mom is hard-working. My mom is beautiful. My mom
is great. My mom did this. This is what I want, and so this was my drive
for me to continue. (Katherine)
So, going through all of those processes needed the determination, the
smartness, the will, like I want to be there. (Mike)
Was like, okay, if there is an opportunity to read, I will do my best. So the
guy that took me there was another stepping stone for me like okay you
guys can do it. If this guy has done it, don’t think that those ones they have
stamps, they don’t have names written like these are the only ones who
qualify. They are not the chosen ones. Anyone can achieve it if you work
hard. (Mike)
When you fall down, you wake up and you clean up yourself and you just
try again. So yeah that inspired me, it’s like, okay, if I can do it that was
my first class. (Mike)
So everything I do, it’s going to haunt me back or it’s going to help me
tomorrow. That thing inspired me much. So those who have done it were
much of my support. My mother is not here to be crying on. I did not have
any family member here in the country, it’s just friends. So those friends
who have done it, because some were there to discourage me. They’re
like, why you keeping yourself stressed? When you talk to them about
55
your problem, they are like “why are you even stressing yourself? You can
live a better life—you have a license anyway, you don’t have to stress
yourself.” But I said no, this is not what I wanted. So that really filled me
with sorrow to hear all that. When you see somebody that has gone ahead
of you, they have gone and done it, I can do it too. (Mike)
Like I say, everything need practice, positive attitude, focus. (Mike)
Yeah. It’s sometimes I don’t always like to have the negative part kind of
follow me or kind of attack my mind and fight with me psychologically. I
always say, it’s always there no matter what; it’s going to be there no
matter what I do, but how am I going to look on the positive side. (Ryan)
Essence Summary
The essence “optimistic determination” led participants to cope with and adapt to
the challenges within their nursing education program. This essence was demonstrated
through the sharing of significant statements from each of the nine participants.
Main Theme: Academics
This theme emerged from participants’ discussion of program characteristics. In
addition to statements regarding general characteristics of the program, sub-themes
relating to testing, language, and technology, emerged. The following statements
illustrate the theme of academics.
But I know another thing was time. Just trying to fit into the curriculum
was a big adjustment. Time, you know, assignments that need to be on
time. You know if your deadline is at this particular time and you don’t
meet the deadline you are getting a zero. (Charlie)
Because first the drive was so much. It was so long, I had to commute
from here to [Town X]. So that was very, very hard. So after that, the
classes, the length of time you are in school, you know, it’s like you are in
school from 8 o’clock until 2 o’clock and there are so many assignments
and a lot of reading. (Katherine)
But the experience and how it structured was very difficult for me.
Because you have, like, 12 credit class and each class has a lot of
56
assignments that need to be done, there are exams coming up. All that
took me a while to get used to. (Katherine)
And the school also, there was a little problem, there was not much in
class interaction. You know how they do those activities where you sit in
groups, you discuss, there was not much there. So it was really hard for us
to interact in class. So for me that was a very bad experience. And I felt
like the school need to do or say something. Not only the school, but the
teachers also needed to put something into place that there would be some
interaction. (Katherine)
The faculty, like, encouraged us to do that, study together, bounce things
off each other, you know, try and get stuff done together because this is
how it is in the real world as a nurse. You are never are alone. You always
want to utilize your coworkers and have people to bounce off. You are
working on a healthcare team, it is not just you. (Debra)
You know, before I came here, after I left the first time, I started to work
for [X Organization], an American organization. I had the opportunity to
write papers, reports, every month, quarterly, so I don’t have that major
issue with writing, so for any assignment, written assignment, anything,
there was no major problem with that one. (John)
You know my expectation was that there is too much focus on the clinical
part, the pathophysiology, the pharmacology, internal medicine, and
surgeries, but most of the focus was on communication, the cultural
sensitivity, how we communicate with patients. You know, I was
surprised, okay, why you know these people, they don’t focus on all of
these, the pathophysiology, the pharmacology part, why they waste their
time on this communication. (John)
One week into the class, they told me I have to drop all the classes. I was
literally forced to drop all of the classes. So now I said, okay, why? They
said, oh, there is one prerequisite that you haven’t done. Nutrition. And I
said, what? I was able to register, because some nursing classes, you’re
not able to register for at all. And I was able to register for the class. I had
met with my advisor. So how did this happen? And I really want to get
into this program. I have already gotten into the program. I don’t want to
be delayed. Because then I have to wait, because it’s not every semester.
It’s like one year. One year you have to wait. So, luckily for me, I called
[College X], and they were offering the same nutrition. And that day that
they dropped me out of that class, that was the final day to add a class.
(Katherine)
You need someone to guide you with how process works. But there are
courses which don’t transfer. Most especially, the most courses which
transfer mostly is those you have your bachelors. More especially
57
architecture and sciences, those won’t transfer. When you did nursing, that
one transfers. But these other things you are high school teacher, those
ones don’t recognize. Most especially, if you didn’t have, if you had a
diplomas—they don’t add nothing. So you end up getting frustrated.
You’re like, why did I waste my time? (Mike)
I think another thing is the people are kind of more interested in the
culture. Because if somebody talks about Africa, a lot of things run in your
mind: Do you guys have schools there? So they didn’t know what was my
expectation; according to them they didn’t know how I was going to
perform. They didn’t know whether I was going to survive the program.
(Ryan)
Sub-theme: Testing. This sub-theme emerged as participants discussed difficult
aspects of their nursing education experience. The following excerpts illustrate this sub-
theme.
And then also, you know, it was like a little bit difficult for the testing for
me since all the testing here is like done in multiple choice. And in
Liberia, the bulk of our testing is like essay. So like they give you a
question and you write about it. . . . And it’s like those answers, like every
one of those answers could certainly be true and they’re like we want the
best answers. Like what do you mean? There is every scenario here that is
true. (Debra)
My most challenging part in nursing school, was the multiple choice.
Because I come from a country where everything is written. Think the
answers, and therefore even to this day it’s difficult to summarize things
for me because we have to write extensively. So when I came here in
order to just pass the exam, I had to put in a lot of effort. Into that process
of elimination, it took me a long time. So that was really, really my
problem. (Katherine)
Another thing that was challenging was the way the education is set here.
Here we have multiple choices. There [in Africa] you explain. It’s more
essay. So by the time you deducting from the essay, you may have the
information I can study the functions of the body. I can give you, okay, the
heart, it pumps blood from point A to point C. But I would be asked a
question about the heart with multiple choices I failed to get it because
four of the answers are presented—you need to pick the best. You have
the information, but applying the critical thinking was one of the
challenging thing. (Mike)
58
Yeah, and comparing the education that I did back in my country and here,
with the nursing program it’s more of, you know, you have to choose an
answer from the questions you are given. Such kind of questions don’t, in
my country, or the previous degree that I did, didn’t have that. Because
you have to write papers. It was more discussed (Ryan).
The first thing in the nursing program, I remember, I made 78%, and I was
shocked. I didn’t expect them to focus most of the questions from the
communication part, the cultural part. I expected more questions from the
science part. (John)
And sometimes the other thing that was a little bit sometimes the room
would get distracting. Somebody would finish like within 10 minutes, and
they are done and they get up and they move their chairs and you get
distracted. So it was a little bit hard to focus. (Katherine)
I think the aspect of nursing that I didn’t get, maybe I struggled with it a
little bit in the beginning, was the aspect of critical thinking. I didn’t, some
questions that I would do, but it wouldn’t make sense why not add the
answer. So I would always remain with probably two answers in the
beginning, so I was like “why not this one?” (Ryan)
One participant spoke positively of testing within his educational program.
I actually did [like multiple choice testing] because I found like, you
know, this is a fair system so nobody can say, nobody can tell me, you
know, you’re being graded upon. (Charlie)
Sub-theme: Language. Within the sub-theme of language, participants discussed
aspects of language in relation to their academic performance.
And that was a little bit complex because it was more intense, we were
very busy, and then I had to take another English courses, Introduction to
Literature, which was one of the requirements for the bachelor program.
But, you know, especially the literature wasn’t easy for me, because, you
know, this Old English I have to interpret and I have to spend a lot of time.
I have to make research a lot. And then my time was more devoted on the
English program rather than the nursing. (Dan)
So the language barrier is the first challenge. And, like, learning a new
language is like studying the new language. It’s different. I took nursing in
Ethiopia in Amharic. So here like it’s completely different, I have to learn
like the language, like the medical terminology. (Grace)
59
Sometimes when we have class presentation or something like that,
because of my accent maybe some students may not have understood the
answer, they may ask me to repeat. (John)
The use of slang words was discussed by also discussed by participants.
Because, you know, at first I got 72 something, and the second test was
68, which is F, and it was very traumatic for me. I mean, it’s not because I
didn’t know the course; there was impact especially from the slang words.
I didn’t know the names of the toys, I didn’t the names to know because it
is really a challenge. So those slang words, those unfamiliar words, was a
challenge. (Dan)
I don’t know that food. It is something new to me. So other students, they
struggle with the pathophysiology and the pharmacology part. I use most
of my time to learn the language and the culture. I think the first exam was
really, I didn’t expect them to focus more about the culture. Most of the
questions I remember were about food types, which food has high sodium.
I know which food has high sodium, but which diet, I don’t remember
even. I don’t know even one American food’s name. Six other questions I
missed, so I sat and okay is the right place for me? (John)
Additionally, participants discussed time difficulties related to translation.
Understanding the questions during the exams and the exams are timed, so
it was very, very hard. Because you had to do 50 questions, and you had,
like, an hour? And not only that, the one hour is because it takes me
nearly, like, five minutes to just analyze the question and translated into
my language and just to try to get that question right. (Katherine)
For me, I have to go three stages back, I have to go get it in English,
process it in my own language, and bring it back to English so that I can
be able to do it. You have to go back three steps. Which is a very, very
hard challenge. I needed more time. Something which was to be taught for
one hour took me an extensive time. More time so that I could process—I
had to go through all those extra steps. (Mike)
On the contrary, one participant indicated that language was not an obstacle in her
education.
Coming from Kenya where our primary language is English, I was taught
English from kindergarten all the way through high school, and so I did
not struggle linguistically. (Emma)
Sub-theme: Technology. Participants discussed technology as a barrier in their
60
nursing education.
You know, there was some parts of nursing education here that was really
difficult. Just let’s say, like, technology-wise, that part was like very
difficult. . . . Like, I didn’t have computers back there, so I was just
learning how to use the computers and that kind of stuff here, you know,
so that was kind of like the difficulty for me. (Debra)
It’s like you find you need to use technology, which you don’t have in
Africa. There is no technology, and I was lucky because I studied in the
city because I was working, and you had your own computer to learn how
to type, but I cannot type like the kids who can type here. So anything you
can do for one hour, I’m going to do for three hours or five. (Mike)
Overcoming Academic Barriers Through Optimistic Determination
While some participants identified positive aspects of academics, many discussed
challenges. When asked how they overcame these challenges, they responded with the
following statements. The attitudes and actions identified by participants demonstrate
optimistic determination.
I really enjoyed it, and I’m proud for, hopefully, I never got a B; I always
got A’s, so that I think made me work extra hard, to be able to study hard.
(Charlie)
Just if you study, if you go prepared to the class and then during the
discussion and during the lecture you more understand what the professor
is talking, what the discussion is about, and then you motivate yourself.
You feel then comfort, being prepared. (Dan)
I also felt very empowered towards the end of my education, because at
that time the attrition had happened so much that in the last semester it
was very empowering that, you know, we are making the finish line. I
think during my graduation we only had two full black students and one
mixed girl, and then there were some other Hmong students, too. But of
the multicultural group, there was just me and another Somali student, and
then one mixed student. So it was very empowering just to get to the finish
line, just to do this NCLEX prepping, and just to begin to really see the
light at the end of the tunnel. (Emma)
Yeah. And I want, like, a better life for my children, for my kids, so. And I
like challenges. And if, like, I decide to do one thing, like, I have to do it
no matter what, like, I have to study hard and I don’t want to like, or this is
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very hard or challenging, so maybe I need to change my path or
something like that. Maybe that’s why, I don’t know. (Grace)
I struggled for biology. I remember, I failed my first biology; I got a D. I
said I cannot be, if I’m thinking to be a nurse getting a D, I’m not seeing
my future anyway. I repeat that class, and I got an A, which inspired me.
It’s like, okay, if I can do it. When you fall down, you wake up and you
clean up yourself and you just try again. So yeah, that inspired me, it’s
like, okay, if I can do it, that was my first class. So, going through all of
those processes needed the determination, the smartness, the will, like, I
want to be there. (Mike)
In the following excerpts, participants identified actions that led to improvement in their
performance.
So I was forewarned, you know, when you go in, you need to make sure
that you study, so I extensively read, and I read the textbook, I read the
med surgical text book twice from cover to cover. And I made sure that I
read extensively other material to be able to be quick and sharp because I
knew my brother told me you get in there, you are an immigrant, you are a
minority, you can’t speak very well English, they are looking to fail you.
So you have to have your guns ready to go. So I work extra hard, and I
read extensively to be able to be successful. Yeah. (Charlie)
The rest of the course was okay because I learned from my mistake, and
then I had to make time management, which was very important. It is
really critical to have time management. (Dan)
That time is this the right place for me to be in the nursing program, and if
I don’t understand the food, how am I going to proceed with the rest of the
program if I’m missing lots of questions focused on culture, food, you
know, I was kind of discouraged at that time. But since I changed my plan,
how to read, which area to focus, I just tried to improve a lot. (John)
So, then, after that, I realized taking the exam in class with the other
students was getting to be a little bit challenging for me. So what I asked
was to do it a little bit elsewhere. So that I can think about the question, I
can really translated into my language and then be able to answer the
question. Then I started to really see my grades improve. . . . So I studied
extra hard. (Katherine)
When I got here. I had some basics of knowledge of computers. There was
a requirement that you had to have computers for you to be in nursing
school. So I took that class, and I passed. I got an A. After getting an A, it
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helps you understand the way that things are done, but guess what, your
fingers are not that fast. But I practice. Like I say, everything need
practice, positive attitude, focus. (Mike)
I would try to reason through, but after I figured out how to answer critical
thinking questions, it just became more just like my other, you know, class
that I had done preparing for nursing. (Ryan)
Participants spoke of reaching out to support systems as a means of coping.
Yeah, and my husband. . . . He is very supportive. He always, like, be
there. He takes care of the kids and everything so I don’t have to worry.
Yeah. He worked full-time so I don’t have to work. (Grace)
Grace also discussed reaching out to her university for support.
Like, the school provided a tutoring program. So, like, most of the time,
when I was like a three-person team, I go there and, like, I make them
check my paper. (Grace)
Dan and Mike reached out to faculty and friends for support.
Then, you know, I learned from my mistake . . . because I spoke with my
educators, with my professors. Yeah, my advisors, and then even I spoke
with the counselor. So they told me, “Dan, you are not getting enough
sleep. You need to sleep in order to retain.” (Dan)
One of the best things was, like, friend was in medical field. Now he is
studying with me. His understanding is more faster than mine. So talking
to him was like he is explaining to me better. (Mike)
Theme Summary
The first theme, “academics” identified factors of participants’ nursing programs
that had either a positive or negative impact on their academic progression. These factors
were revealed through excerpts from participants’ statements. Sub-themes of testing,
language, and technology were explored. Participants overcame challenges through the
use of optimistic determination.
Main Theme: Relationships
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This theme emerged as participants were asked to describe their teachers and
classmates. Through analysis of the transcripts, four sub-themes emerged and included
(1) faculty, (2) classmates, (3) language, and (4) clinical: patients and classmates. The
excerpts that follow illustrate the importance of relationships within the participants’
nursing program experience.
Sub-theme: Faculty. When describing their relationship with faculty, participants
were primarily positive. The following statements demonstrate the positive aspects of
relationships with faculty and highlight the participants’ perspectives on what makes
faculty supportive.
Their willingness. For example, you know, if I wrote a paper that I didn’t
grammatically spell things or I missed things, they’d call me and say, you
know, we need to look at your paper. We need to work on this. There is
areas on your paper that you need to improve on, and, you know, there is a
teacher who in my second semester class advised for me to go to the
Learning Center and do some brushing up on my writing ’cause
sometimes I was writing a lot of sentence fragments. So calling me in and
informing me how to make improvement I think was good, and also being
approachable, responding on time to questions that I had, and they made
me feel like, you know, I’m not scared to come to you because you are
approaching me versus me waiting to the end to try and approach you. So
opening up quickly to the students, making yourself accessible I think
was. . . I think working with [Professor X]. I think she is somebody who
stuck with me and made me feel nursing is for me, despite me wanting to
pursue medicine and medicine as a final career. She encouraged me into
nursing, and I felt my need for service was very important for multiple
reasons. During breaks, for example on clinical breaks, she would come sit
with us students, and she would talk about issues that were not relevant to
nursing. She had the human connection. It’s not I’m the instructor, I’m
superior, we’re distinct in our self, there is a difference between us. So she
came and she talked to us. She took us on tours, like the last of the
clinicals. Continually during our clinicals, she always took us into the
patient’s room and talked to both the patient and us and made a
connection. She called us in her office hours. She complimented us on the
good work. It was just rare things that you hear on a daily basis like, oh
you are doing a good job; it’s always you are on the eye. So I think my
whole clinical experience the first semester with her and the fourth
semester with her, she made me want to do nursing, feel like I like to do
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nursing. You know, it’s not, yes, it’s a very critical career where you are
dealing with people’s lives, but she made it feel like, yes, it’s critical, but
it’s human, and it needs to be associated with joy. We need to like what
you’re doing, and emphasized the point of caring. (Charlie)
Because you know, every professor, every instructors have to treat you
like the other students. And then there is no specific time they can talk to
you. Although, yeah, they were very supportive. They give you feedback
on time. Even there was an alert system if your grade was down. (Dan)
So it was kind of nice to have, you know, those kinds of teachers, because
I mean this is nursing. We are playing with people’s lives. You really need
to take this seriously. You know, you can’t go do it over if make a huge
mistake and have a sentinel event and someone gets hurt. So, our
instructors, they were pretty much like very militant about that. [X] school
has a great reputation as a nursing school, and we’re living up to that
name. If you can’t cut it, good-bye, go find somewhere else to go. Come
back when you’re ready to play ball. So I really, like, appreciated my
instructors. . . . I thought they had a wealth of knowledge. They were
always very helpful. They were open to questions if, you know, I didn’t
understand something. There were other African girls in the program with
me, some of them from like non-English speaking countries so English
wasn’t their first language. For me, English is my first language so, like, if
we didn’t understand something, like, culturally or whatever, their doors
were always open and we could go in there whenever and ask questions.
(Debra)
Debra continued her discussion of her nursing faculty by offering a story of a particular
faculty member she felt made a difference in her ability to succeed.
So one of my instructors, just a lovely, lovely lady (I don’t know if she is
still over there or if she is retired). You know, she just took a special
interest in me. I didn’t even know she was, like, paying attention to me.
You know, she would ask me all these questions and stuff like that. So,
like, after the first, I think it was the first or second, we were doing terms,
then just before we went to semester, after my second term in the nursing
program, I come to class one day, you know, and she said, hey, come in
my office after class, I’ve got something to tell you. So of course I’m like,
oh boy. . . . So I get in there and she is, like, you know, I see how hard
you’re working, and I know you’re working nights, and I know about
everything you’ve been going through. And I’m just like, who told you? I
guess one of my study buddies, like, kind of told her, you know. And she
is, like, I just want you to know that help are here for you. I’m like, really?
and she’s like, yeah. She hands me this paper, and I look on the top, and it
says student nurse scholarship for minority student, and I’m like, okay,
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because I had tried for financial aid and I got turned down. Apparently,
my parents made too much money, you know, and it’s like whoa, I kind of
live at home, but I paid in rent. Why are you looking at my parents’
income, you know. So then I had to, like, pay my way through school, and
what I couldn’t pay for, I had to take loans on my own. So she gives me
this, you know, sheet, this application, and she’s like, if anybody qualifies
for this, you do. She is like, you have good grades, and you have
everything that they need. So I fill out the form and handed it back to her,
she handed it in, and like, two weeks later, I get this huge check to pay for
the rest of, you know, that school year and the rest of the next school year,
so literally it paid the rest of my nursing program. (Debra)
Debra concluded her discussion of her nursing faculty by offering the following
statement:
So I’m just, like, so happy that the programs here are so diverse and
inclusive, you know. They don’t really make you feel, like, excluded, and
a lot of the instructors and people here are just so helpful. I mean, you
actually really have to be, like, living under a rock to tell me that you went
to a nursing school here and you really didn’t get the help you needed.
(Debra)
Emma, John, and Katherine also added insight into their relationship with faculty.
When I got into the program, I began to see my teachers as friends. . . . I
felt empowered when, during clinical, my teacher would say I would make
a good nurse, just those positive affirmations during clinical, or even after
a paper, very encouraging comments. (Emma)
Oh, they’re very nice. I haven’t seen any different treatment from the rest
of them. They have good respect, they understand me. . . . So that was the
highest percent, even the instructor told us while she has been teaching
this program, I had scored the highest, 89%, and she talked about that to
all the students in the classroom. (John)
Oh, I have been blessed. I’ve met wonderful teachers. I can tell you that,
for some reason, some of them took to me very well. They say, oh you are
so pretty, oh you have nice teeth. All these things I didn’t know that they
are things that you can comment on people, so. So people really liked me
during nursing school, so I am blessed. So I really didn’t have any
problem with teachers. (Katherine)
Katherine went on to discuss one particular instructor that she felt contributed to
her success in becoming a nurse.
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And I met one instructor a very long time ago. She was teaching all the
huge units. She was teaching cardiac, respiratory, skin, and these are big
units, and she was older. So at one time, she came to class and she said,
my mom is very sick. But one thing I observed some of the other students
didn’t really like her style of teaching. Like, I said she’s older, so her
methods of teaching was a little bit different. So a lot of students really
didn’t like her class. But when she said that, for some reason I just took it
in. So every day, I see her in the hallway I asked her, how’s your mom?
And she’d say, oh, she’s fine thanks. Every day throughout the entire
semester! So it just happened that that was one semester I was having a lot
of challenges. And I didn’t do very well in the class. I was down by one
point. So I went to her, it was the end of the semester of course. Nursing
school you get kicked out if you don’t pass the class is like a progression.
So, I just went to get my grade and she said, you know you are down one
point, but you know what, you always ask for my mom. Every single time.
She said, I will give you that one point. And she gave me one point. And I
felt so blessed that day! Because I was so disappointed going to see her.
So she just made my day. So I have been lucky to meet instructors. Not
that they’ve helped me every time, but I’ve just been lucky that I don’t
fight with them. They don’t dislike me for any reason, and I don’t dislike
them for any reason. . . . That acknowledgment was very, very good.
(Katherine)
Mike also shared a story about a particular faculty member that made a difference in his
education.
And especially one of my professors, [Professor X]? She’s a mother and a
half. She is one mother who listens. I think because she has kids she has
adopted from different countries? She kind of has that. You know, if
you’ve never been to people, you don’t know the shoes they’re wearing.
You’ve never been out of this country, you don’t know what’s happening
in the other world. It’s different. So she could talk to me like a mother can
talk to you. Like, what is the problem? Can you approach this thing from
this end? Can you listen on this end? Because I think she has a lot of
experience and it felt like okay, she’s taught me so much. To me it was
like, if she has a few minutes to listen to me, that was the most important
thing. . . . And when you get this somebody that will, like, listen to you,
you kind of open up. But if you find somebody doesn’t give you that time
to listen, then you are struggling to speak that English, you close
everything. You close in your cocoon. . . . The one thing [Professor X]
taught me: you can do it. I see you have potential. You have these goals.
You have this in you. It’s that you need to focus, and you can do it. Focus,
don’t let fear pull you down. Don’t see anything in these, all these people
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are going through it the same. But maybe they don’t show it. But if you
close everything to yourself, you’re going to fail. The one thing is that
you’re trying and you are doing your best. That really put be fair. I wrote
things. Simple words. They really made me like, okay, I go home. She told
me this, and I don’t want to disappoint her. (Mike)
Ryan described his nursing faculty as positive and supportive.
But I think the other professors were really good and really understanding,
and that would keep me going. . . . I think I had the best professors. There
were willing to help me. They were willing to sit down. Whenever I had a
challenge, they would give me direction on how to do things. Most of
them were really appreciative of what I do. I received a lot of positive
remarks both from the professors and also on the clinical side. (Ryan)
While many of the participants identified positively with faculty, some participants
identified feelings of isolation and discrimination. The following statements illustrate this
negative aspect of faculty relationships.
Because the other teachers never cared. They don’t have time for that.
They don’t understand, it’s like okay you are here. How did you get here?
(Mike)
So, like, I don’t know. Some of my teachers, like, they are very talented,
and I love all of my teachers, but, like, some of them, like, they don’t want
to accept, like, how— they know my grades are, like, I'm doing a little bit
discourage, but they think, they, like, they don’t consider, like, me as
equal as the other students. Like, they try, like, they prefer the other
classmates to explain things or to answer some questions. (Grace)
This came when we had one professor in class that, I don’t want to say
kind of more discrimination, because I don’t think that was discrimination,
but I don’t know whether he didn’t like me in person, so it was always
kind of more discouraging. You ask him a question, and he was totally
answering a way that you feel that you don’t belong here. (Ryan)
Sub-theme: Classmates. When asked to describe their classmates, participants
presented a portrait of both positive and negative interactions. The following statements
represent the positive influence of classmates on the participants nursing education
experience. In these first statements, participants describe the use of study groups and the
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establishment of friendships. These relationships provided both academic and emotional
support.
Yeah, I had friends from my classmates. We used to work even as a group,
but sometimes, you know, when you work as a group and then if you don’t
study, I mean study group. We used to study and sometimes the study
group was fine, and sometimes, you know, it was a tough time. Instead of
studying, instead of discussing, you spent a lot of time just talking social. I
had good integration with my classmates, although not with everyone, but
at least I had some friends. (Dan)
You know, it became sort of like a family, so we each had, like, these little
study groups. So we had a bigger study group where there was, like, about
fifteen of us girls in the group, and then we, like, had smaller study groups
so then was like about maybe like six of us in the smaller study groups.
And then we had even small study groups where there were, like, three. So
we kind of, like, broke it up like that. We would meet in the bigger group,
and then the smaller group, and then in the smallest group. Because, like,
say there were three of us that kind of live really close by each other, so
we would study in our really small study group and get prepared to go to,
like, the six-person group, and then get prepared and go to, like, the
fifteen-person group. And we kind of stuck with that format up until we
took Boards. (Debra)
I would have never gotten through that program without my classmates.
(Debra)
Because there was only four of us, you know, there so obviously we were
in there, but we had someone from Russia in our group, we had someone
from China in our group, and then we had, like, our wonderful American
classmates. They were a great source of wealth and information. (Debra)
Exactly, you know, and like I said, you know, I had, like, two of them
over there that, like, they were like moms to me because I was the
youngest in the program at the time. And, you know, coming from Africa,
leaving my mom, this was the first time I’ve ever traveled without my
family; they mothered me real well. And to this day they continue to be
my mom, you know. (Debra)
Also, I think most of my colleagues were really supportive. So that’s a
place that I kind of miss. We had a group a group that we could discuss
stuff. (Ryan)
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Participants felt valued when asked questions by their classmates. In addition, the
opportunity to share their culture helped to create an inclusive environment and
relationships.
I think, unfortunately, I guess there is an unspoken expectation that will
these students really make it or not. Talking about from the white students
towards us when they would see the multicultural students struggling in
semester after semester, and seeing you make it through, they really begin
to value you, they really begin to see you as a different student. Even now
they want your input. Even now asking for study strategies and tips; did
you do this assignment, how do you think we should do it? Whereby
before there was not that kind of interaction, so I think just being validated
by your own colleagues really, really empowered me, and encouraged me
and showed me that there is not much of a difference between us. (Emma)
There was one presentation where we had a group assignment to prepare
on one culture, to do presentation on that culture. In our group, we picked
the Ethiopian culture. I’m from Ethiopia, and we did a presentation on
that, and every student was really surprised with the cultures, and the way
we presented them, and you know that day I felt good. Okay, so people
understood me, they really interested to learn my culture. . . . Yeah. That
was a pivoting point, and I felt good for the first time, okay. People are
learning from us about some different culture. You know that was the
longest presentation from the other groups. They had lots and lots of
questions coming from the students and from the instructor. Some of them
were working as a CNA, and they asked me different things about the
patient that is from Africa, and how it was hard to communicate with the
patient, how to make them and difficult to make them happy. We talked a
lot and that was very turning point for me. (John)
And also my classmates, also they always felt like I know more than them.
They would ask me to explain things. They would say, oh [Katherine],
come here and explain this. So that kind of made me feel empowered in
caring for them, because I would explain something to them, and then they
would get it, and then we would continue. So that’s makes me feel
empowered. (Katherine)
So for me it was a regular class just like any other class, but, you know,
for my classmates they were all kind of asking me so, you know, no
offense, but since you are the only black how do you feel? Do you feel
kind of goofy, you know, questions that it was good for them to ask and
then get clarification. But for me it was equalization. (Ryan)
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In contrast, participants spoke about isolating experiences within the classroom. These
isolating experiences resulted in feelings of segregation and discrimination. Some
participants mediated the effects of this isolation by developing relationships with other
minority students. Others were resolved to continue their program despite the difficulties
they encountered.
I myself would not say that I necessarily associated with the black students
only. I associated more with the multicultural students. I had Arab friends,
Somali friends, Hmong friends, and those are the people who, and I think
we had a girl from Ecuador or something like that, that we studied
together so it was a bigger, multicultural group. We kind of huddled
together and helped each other through the program. We studied together,
we would prepare for exams for together, challenges with papers and
everything. We would call each other. (Emma)
The material wasn’t tough, but the exercise in the classroom, how
everything was presented, I think, was the biggest challenge for me,
because, for example, when the instructor said, you know, you need to
participate in group studies, there is differentiation, like, people tend to
segregate based on their racial perception of self. So there is a lot of
discrimination where, you know, let’s do a group study on listening to
lung sounds. You find the African students tend to go to African students,
Americans tend to go to Americans, whites tend to go to whites, Indians
tend to go to Indians, so it is more of a segregation of some sort, and if
you didn’t have anybody from your culture, from Africa or from away,
then you are stuck and you are having to go through trying to fit in, in
groups where people don’t want you to fit in when you are trying to study
and it’s pretty hard. . . . There were other minorities, but I was the only
African, and in that class is when it really stood out to me that, you know,
people associate themselves with people who they feel comfortable with,
that they like, but overall the classes were predominantly white with a few
Africans. (Charlie)
And then if we had experiences that was, like, completely different from
them, and we would share these experiences, they would look at us like
we are weird. . . . So when we went back to class the following week, my
instructor thought it was, like, very interesting. She really wanted me to
share my experience with the class, you know, so when I was sharing it,
all the other African girls in there, even we have like one girl from China
and I think another girl from Russia in our class, and they totally knew
where I was coming from, and the American students were like
completely horrified, like I did something wrong, you know. (Debra)
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When I got in, I began to identify who would be my sisters, who would be
the people I would study with so, you know, within no time I would see
this is the section that the black students would sit and the front is where
the smarter students would sit, and then behind were the noisier students,
so when I got into class I began to see the profiling take place. . . .
Classmates, I would say there was the profiling, just the profiling even
where the different students would sit, and who would talk to who and
who would share with what. Of course, and I’m sure you’ve heard this
before, but when we were given group assignments, sometimes the white
students would not have confidence and faith in what some of the minority
students would be doing in the activity of the work. So when there is a
group assignment and they are dividing the work, okay you take question
one, question two, question three, or however the assignment is, there is a
tendency to assign something that is very easy or non-challenging to a
minority student because maybe not having faith in their ability to
perform, so I experienced that a couple of times. (Emma)
We were all immigrant, all from West Africa. And the first day of class,
we all met. We didn’t know each other, just like I’m meeting you now.
And then we did, of course, the general introduction. And so I went in
front of the class and I said, you know, I want to make it my goal to get to
know everyone. So I introduced myself, and I went around and I did the
same thing. But one thing I realized that the students were not that open
with us. So I would say hello to you in class and then in the hallway I’ll
see you, then you turn away your eye like that. So that’s the kind of
behavior they started exhibiting towards us. I observed. So then for some
reason, it just happened that all of us were observing the same. . . . So then
we decided and that was the day also I decided, I said, well, I will give
each student a second chance. . . .So, like, after the class had progressed,
like, two weeks I went again and I introduced myself again. You know, I
am Katherine. We just tried to open that door because we are all in school
for a common goal. To finish and then move away. Go away, find a job,
you’ll never see me again. So, that was my goal. So accommodate me, get
to know me, you will learn something from me, I will learn something
from you. And, that was the mentality I had, but apparently no. So after
the two attempts, I didn’t put forth the effort. So then, collectively, we all
agreed that we cannot get through to them—to the white students. So we
kind of kept ourself distanced. (Katherine)
Katherine went on to describe the relationships formed with other African students.
Yes, we chose to do everything together. Because we said, we are
Africans. We’ve come a long way and we are here for this goal . . . is to
pass, study hard for this exam, pass. So what we did together, we studied
together, we did everything together. We became very close. Almost like
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inseparable. If you see four of us—the other four knows where the other
four are. Because we stood out on the campus. It was very few blacks.
(Katherine)
Finally, Katherine identified differences between her relationship with classmates within
the classroom and clinical settings.
We found it very interesting that during clinicals, we all have the same
need. If we don’t understand something, I go to you, you explain to me,
you come to me, I explained to you. But when we meet to in class we are
two different people. So I found that’s very, very strange during that time.
And it was very difficult. But they were a little bit more receptive because
during the clinicals because we depend on each other during clinicals. And
we are smaller group. And we are force there to assign patients to each
other. So you can’t avoid that communication. But still, when that was
over we just go our separate ways. (Katherine)
Mike offered a number of comments relating to his classmates. In the first comment,
Mike discussed his struggle with being the only black student in his class. He turned to
Kenyan students in other classes for support as he struggled to establish relationships
with non-minority classmates.
In my nursing program, the encouragement I got from the Kenyan people
at class. It is those people you meet, either they are nurses, like when I
went to South Dakota I was the only black guy in the class. So sometimes
I would come to class frustrated, because I didn’t work in South Dakota,
my license was not in South Dakota. And now I was living on my credit
card. And now, why am I here? Number one, I made the wrong decision. I
had an admission, but I was not ready. Why am I here? Jason was telling
me, no, Mike you can do it. He was my only brother down there. Because
you finish class and everyone disappears. I be like, they don’t like me?
(Mike)
So that is one thing that’s like, being that I was the only black in my class,
when you’re speaking to fellow classmates. They’re like okay, somebody
is going to see their kids. Some are going this way. They’re like, wow!
Now here who am I supposed to talk to? That was the most challenging
thing. Like, who am I supposed to talk to? (Mike)
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And now here you’re going to a class, with a teenager. Telling you about
their boyfriends in class. You are in that class. Another telling you about
how they went out and how they did everything, and you’re like, okay. My
God. This is what I will be going through every day? It’s a big challenge.
A big culture shock. (Mike)
There is not that teamwork between the students. It is different. You know
right now you are teaching at a computer whereby people can just sit
down and talk to the computer. You get the message. That communal
thing is, like, key to our brother from here who have never been outside
the world. They perceive you as stupid. Somebody went to school here,
you came from Africa, maybe you have some knowledge or skills in
different area. They perceive you as stupid. That is one thing that is also
challenging. (Mike)
Ryan described a similar educational environment where limited diversity was a
challenge.
First, I was the only minority student in my class. We started with 40
students, and then we ended up graduating with only 37, so I was the only
minority and also of black African descent, so I can say it was more
difficult for me, but because I was used to diversity—I had gone to school
down in Omaha. (Ryan)
Sub-theme: Language. Participants identified language differences as a
challenge to the development of relationships with faculty, classmates, and clinical
patients.
And then as I said, the language barrier is big, it weighs big. I don’t know
how you understand the other community, but especially for me, you
know, although I may have just basic communication skill in English. The
accent, sometimes they don’t understand you. Even you, you may not
understand me even now, but I try to learn every day, you know, because I
have to speak the American accent in order to communicate with the
community or integrate with the rest of my classmates, my professors,
with patients, with family. . . . And then if someone don’t understand what
you are talking about, it is really hard. You have to make them understand
what you are saying. So, when this happens, you tend to lose your
confidence. Okay, and then you try different ways to convey your
message. So the language barrier is very great. (Dan)
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But, you know, like, initially it was like the minority students stuck
together pretty much, because, like, you know half the time most of the
people in the class didn’t even understand what we were saying. And we
would be talking and they would be, like, huh, huh? And it’s like, we’re
speaking English. (Debra)
Most of my classmates are, like, how can I describe it, because, like,
English is my second language, so I don’t speak much. So, like, they think
that they know different from me. They consider, like, I don’t know
nothing, so I don’t know how to described them, like. . . . So, yeah. Even,
like, sometimes people ask me to repeat myself over and over again, so
that makes me anxious and I couldn’t find words to speak or answer
question. . . . Because I look different, I speak a different language. Like,
English is my second language. I am just learning English. I still, like,
learning, trying to improve my language. . . . But, like, sometimes I got,
like, a patient or family member like who couldn’t understand my accent,
so that’s a little challenging. (Grace)
So that is the problem when you come here, you got to have that big
transition. It’s like, people you talk to in English, they say what are you
talking about? You don’t get them and they don’t get you. So it is a
challenge. (Mike)
One of the challenges first, and I know I didn’t revisit that, was the accent
that we have. Sometimes most people don’t understand. They will ask you
what did you say, what did you say? . . . Some people can’t understand us,
and we don’t blame them for that because they have never probably had
someone talk like that. So sometimes it’s like you try to explain
something, but it doesn’t go well on the other side. You see a lot of
questions on somebody’s face. (Ryan)
Sub-theme: Clinical- patients and classmates. This theme emerged as
participants made connections between the development of relationships and the clinical
environment. In some cases participants experienced discrimination as a result of their
appearance, gender, and/or language. In other cases, participants felt valued as patients
attempted to understand their culture and validated their care.
I think OB clinicals was one that I felt, you know, completely detached
because number one, not only race, but gender. You never get to see any
OB experience, and it was you are nursing student, no, no, no. So me, my
OB clinical was based on theory. I never saw anything, so that was one
part, being just rejected over and over saying no, no, no, no. I think that’s
pretty much the only . . . (Charlie)
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Also there was a point where I went to clinicals and some patients would
totally refuse you to give them care. And, you know, you keep on asking
yourself why, why this, so when I am giving care that I have to be
selective, you know. If the patient say no, there is nothing you can do. You
have to, you know, stop giving care. (Ryan)
While Ryan described negative experiences with patients, he also provided an example of
how his cultural differences helped establish relationships with his patients.
Some people like to know more about your culture. They’ll tell you, I see
you have an accent, where are you from? You tell them, you know, I am
from this country, I am from Africa, this country. They want to know
more. They appreciate how you take care, how you take time to talk to
them, how take time to share your culture, how you take time to do what
they want you to do and that way you feel more empowered. You feel
somebody appreciates what you are doing. And that happens quite a lot,
you know, most of my patients really appreciate what I’m doing. (Ryan)
Similarly, Emma reported feeling empowered when recognized by her patients.
Even during patient care in the clinical, getting good feedback from the
patients about my care helped me to feel empowered. (Emma)
Finally, Charlie provided an example of how his culture impacted his relationship with
his patients in the clinical setting.
You need to be very polite. Calling people with their first names, I think
that’s another thing that I had to learn. Because we call people with their
last name was, people older than you, signify them with their last name.
And this was mainly with patients as most of the patients are older than us,
and you don’t go into a patient’s room and say, hey John, I have—. You
always try to be respectful: hey Mr. or Mrs. Smith, I have your
medications. You have to make adjustment because some people don’t
want to be called Mr. Smith, they want to be called John, so you need to
make sure you’re understanding, because you don’t want to rub the patient
the wrong way then they tell the instructor and you are being rubbed the
wrong way. It’s something I struggled with in my clinical. (Charlie)
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Overcoming Relationship Barriers Through Optimistic Determination
Participants offered the following comments that demonstrate their response to
relationship problems they encountered during their nursing education. The following
excerpts illuminate their source of motivation as optimistic determination.
The accent is the first time you see some discomfort with, but once they
see that you are there for them, you fight for them, they start to trust you
and respect you. (John)
So sometimes you come from clinicals, you are crying home. I’d be like, I
don’t have my mama here nor my father, I’m by myself. So everything I
do, it’s going to haunt me back or it’s going to help me tomorrow. That
thing inspired me much. So those who have done it were much of my
support. My mother is not here to be crying on. I did not have any family
member here in the country, it’s just friends. So those friends who have
done it, because some were there to discourage me. They’re like, why you
keeping yourself stressed? When you talk to them about your problem,
they are like, why are you even stressing yourself? You can live a better
life—you have a license anyway, you don’t have to stress yourself. But I
said no, this is not what I wanted. So that really filled me with sorrow to
hear all that. When you see somebody that has gone ahead of you, they
have gone and done it, I can do it too. (Mike)
That was going to be a challenge in my profession because if somebody
say, I don’t want your care, and you have been assigned, what do you do?
But I realized in every community, and in every culture, we get such
people, and they have a choice to refuse, you know, who is going to give
them care, and that is why I was like I am not going to be discouraged. I’ll
fight on. . . . So it’s encouragement the people around you and what you
see, what you want to accomplish, so those three things kind of help me to
forget about what happened and move on. . . . So that being a challenge,
on the other side some people like to know more about your culture.
They’ll tell you I see you have an accent, where are you from? You tell
them, you know, I am from this country, I am from Africa, this country.
They want to know more. They appreciate how you take care, how you
take time to talk to them, how take time to share your culture, how you
take time to do what they want you to do and that way you feel more
empowered. You feel somebody appreciates what you are doing. And that
happens quite a lot, you know, most of my patients really appreciate what
I’m doing. (Ryan)
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In some cases, participants turned to avoidance as a means of coping with relationship
difficulties. Others persisted in developing relationships that created a supportive
environment.
I think my coping mechanism was, I just avoided it, because I just said
outright, you know, I’m not going to be an OB nurse. So, I think that I did
an avoidance strategy versus dealing with it. (Charlie)
So after the two attempts, I didn’t put forth the effort. So then,
collectively, we all agreed that we cannot get through to them—to the
white students. So we kind of kept ourself distanced. (Katherine)
Then I spoke to the director of the nursing home. I told her some resident
told me this and she told me that resident, that particular resident has had
issues with nurses, and she tried to calm me down. (John)
So I made sure that after class, I would remain behind, even if was just to
say hello to the teacher, go and say hi, speak with them about an
assignment, tell them a little bit of the challenge that I faced doing it, ask
them to clarify things for me, email them, you know so they would know
me as a proactive student, and just to develop that personal relationship
that even if I struggle they know [Emma] would come to ask for help, or I
know [Emma]. (Emma)
In some cases, Emma chose no action when confronting relationship challenges.
I just kind of went with it, and that was what it was because, yeah. I don’t
remember ever opposing, yeah, and sometimes when you give your input
in something it’s kind of bashed down and not listened to as much, but I
just kind of went with the flow. I mean, if in any instance I felt
disrespected, I would speak up about that, but I was compliant. (Emma)
In the following excerpt, Emma described taking initiative to improve relationships for
herself and others at her school.
I wasn’t on the SNA Board before, but when I finished my third year,
going into the fourth year, I felt like minority students are not represented
in that group because all of the Board members were white students, and I
saw that there was something wrong with that picture. Our voices were not
being heard. We silently complain about things and nothing ever happens,
and we just wallow in that lack of having a voice and having our needs
expressed. So I was collaborating with one of my mentors, an English
professor who we became very good friends and are working on different
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projects together right now, so I began to tell her, you know what, I think
it’s important for us to have representation of multicultural students on
that Board. What can be done about it? So we began to talk, and she
encouraged me, and she told me, [Emma], why don’t you vie for a
position as a multicultural chair on the Board, and represent the
multicultural students? So after that, I went and I spoke to some of the
nursing faculty and told them about the idea, and they really, really
supported it. We were having these conversations in the summer. In the
fall, immediately, she began to send emails to the current Board and told
them, you know what, there is a need for a multicultural chair position
because they need their voices represented, and we’re going to go ahead
and put in this position. It won’t go through any documentation or any
voting or just a lot of things that sometimes take time to make some things
happen. And she is like, we are just going to bring the position about and
[Emma] is the one who is going to be heading that, so she is going to be
part of the SNA Board. So you can bring things together and we will have
a meeting just to introduce her and what she is going to be doing. So that
came about and they introduced me to it, and I began to work with the
students. So when I came into the position some of the things that I did is
that I organized, like, two meetings a semester for multicultural students. I
mean it was open to everyone who wants to come, but mostly
multicultural students were the target that I wanted to have at the
meetings. So they came to the meetings and we just kind of talked about
what are those that we can do to support one another, what are some of the
things that are obstacles for us, what’s making us not make it, what needs
to be changed, what needs to be done and what experiences have we had.
(Emma)
Family support was important to Emma when discussing relationships.
I give credit to my family that really supported me through getting into the
program, and even in the program. (Emma)
Finally, Emma utilized university resources to establish supportive relationships.
So I would say that support system within the program was good, and also
my family and friends around me really supported that, so I would say I
had a good experience through my nursing program. [University X] is a
very small school, so it’s very community oriented, and everybody knows
everybody, and everybody knows everybody’s major if you really want to
know. They have this office called a MIPS Office. It stands for
Multicultural and International Programs and Services. It supports the
multicultural students on campus, and so within that we have events and
we have just social gatherings whereby other multicultural students would
meet with each other and you get to know each other. So through that
channel, I was able to meet those big sisters and identify with them.
(Emma)
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The following excerpts demonstrate how participants turned to faculty and friends for
support.
The one thing [Professor X] taught me, you can do it. I see you have
potential. You have these goals. You have this in you. It’s that you need to
focus, and you can do it. Focus, don’t let fear pull you down. Don’t see
anything in these, all these people are going through it the same. But
maybe they don’t show it. But if you close everything to yourself, you’re
going to fail. The one thing is that you’re trying and you are doing your
best. That really put me fair. I wrote things. Simple words. They really
made me like, okay, I go home. She told me this, and I don’t want to
disappoint her . . . more especially, if it wasn’t teacher, and friend in South
Dakota I would have quit. (Mike)
If my friend is home, that is the social place I can go. And talk to him in a
few minutes. Sometimes friend asks what accent like me, so he’s from
Ethiopia, English is his second language. Sometimes we don’t even get
along. They like, oh man! Sometimes the wife and kids are talking their
language, I’d be like, what am I doing here? It really helped me a lot.
(Mike)
Theme Summary
The theme “relationships” included the sub-themes of faculty, classmates, and
clinical: patients and classmates, and language. Relationships were identified as both
supportive and unsupportive and are described in the excerpts provided. Participants
overcame barriers and challenges relating to relationships with optimistic determination.
Main Theme: Competing Demands
The theme “competing demands” was revealed as participants were asked to
describe their nursing program experience. Participants identified a number of
occurrences and situations that detracted from their studies. The participants’ statements
focused primarily on work and family responsibility, which are identified as sub-themes.
The following statements illuminate the theme “competing demands.”
Sub-Theme: Work. Eight of the nine participants reported working while they
were enrolled in their nursing program, with six of the participants working more than
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part-time. The following statements express the challenges participants faced while
attempting to balance financial and academic responsibilities.
I used to work at [facility X] full time, and then full time for the school,
which wasn’t easy. It was very, very busy. You know, you feel a lot of
frustration, but you know, I was working hard both at school and at work .
. . my agreement with the place where I used to work was twenty hours. I
used to work three, four, five days a week, ten hours, and then overnight. I
had to spend all night there and then going back to school again. It wasn’t
good. (Dan)
So, I told you how I came here and I had to work to get the rest of my
family even though I didn’t really have time to be working sixty hours a
pay period. (Debra)
Another challenge was balancing school and work. I was working full
time on campus and I never had another off-campus job. Sometimes I
would work the night shift, leave work at seven, come shower, be in class
at eight, making it through with some coffee and dozing. (Emma)
Then while I was in the nursing program, I took classes for the certified
nursing assistant, CNA. Then I worked as a CNA while I was going for
my associate program. (John)
You know, my wife works full time, and I work only on the weekends, so
I have more time to attend class and go to class on the week days and have
more time to read. (John)
So it was a challenge on that I got that D because I didn’t know, because
the classes challenging, I had a job full time. Two. I had two jobs. Then I
added this class as 12 credits. Then this biology I need to study. Then I’m
going to the teacher, and I’m, like, tired from work. Then this lady that is
teaching in front of me is telling me 1000 things about photosynthesis.
Like what is this going on? And at other times I was doing a job and then
my baby was born, so I can say it was pretty tough, but, you know. (Mike)
Participants voiced a number of reasons for working while enrolled in school. For some,
family responsibility was the basis for their decision.
So, you know, I was trying to cover myself, even helping my family back
home because I have massive responsibility back home. I used to take the
refund and then send the money back home because they don’t understand
what’s the challenge here. (Dan)
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That never ends for us Africans. That’s why it is very, very hard for us to
go to nursing school and not work. Because not only do we have families
here, but we also have families back home that we care for. (Katherine)
You know, as I told you, you come from Africa, people have this
expectation. You are going away, you are going to send money back
home. . . . And problem, like, my father was sick. Was misdiagnosed for
cancer. Who was to pay? I was a CNA. Paying $1300 every 21 days. . . .
You need money, you need to save this daddy’s life . . . and you feel like,
oh, let me not pay my car today, send you the money so that it can help.
(Mike)
Participants also voiced concerns over acquiring debt and identified this factor as their
reason for working while enrolled in nursing school.
Just taking loans—loans and I would be, you know, I would be dead.
(Dan).
I mean, take loans for everything that you expense in the school, but the
impact or the consequence would be very much. Yeah, very much
different. So I was trying to minimize. To take a limited amount of loans.
And then to achieve it at the same time. For the nursing program that was.
Otherwise, there wasn’t any motivation. (Dan)
But I think for me it was like, you know what, I have to make it, and I
don’t want to sign a loan. Even it got to a point where it was so hard
financially, and I went to speak to an advisor at my school, and she was
like, [Emma], you’ve made it this far and you know what, we can sign a
$6,000 loan, you know, and then you could go on average gradually to
$20,000, and it would be awesome. I looked at her, and I don’t think that
is what I want. I mean, I took the forms, but when I went home I prayed
about it and I said no, I don’t want to do any loans. So I talked to my
family, so how they could support me, and it was my goal to finish debt
free. So financially that’s a hurdle that I make sure I balanced, because I
had to cut my hours at work, but then I would not have enough money and
then I’m not able to register because you still have a hold, so that was
something. (Emma)
Sub-Theme: Family Responsibilities. In addition to financial responsibilities,
participants also experienced pressure to uphold family responsibilities. These
responsibilities challenged the participants’ ability to stay focused and made it difficult to
dedicate time to studying.
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This is an education. I have to study hard, forget. I used to miss, I had a longing to visit family members or friends here, but I can’t. Just like missing my family. Even if they call me, I didn’t have any communication with friends because I don’t have time. I have to work, I have to go to school, I have to spend with my fiancée. (Dan) So coming here was not only that I was by myself; I carried all of the
problems from Africa. They were on my shoulders. . . . I wanted to fix
them. Five years down the road, I tell you today, I look at back. I’ve done
as much as I could. Because I come from a communal culture. So you feel
like all the problem that you are they’re there for you. You want to be the
bridge to all those people. Be better. For the first time, somebody has died
in my family was my father. And I was only 21. . . . Miles away. Every
decision is expected from you. You are the power of attorney, you are
everything because you live in the U.S., not because you are the all in the
family, because you are in the U.S. You leave class, you getting phone
calls from Africa. You would listen to the way he’s breathing, he’s going
through all those things, you have a class test coming up. It’s too much! I
came back, stressed and depressed like no, what was I to do better. . . . So
those things were the much stressor in my life. It’s like, if I didn’t have
those luggages is from Africa, it is easier to concentrate. You know, like
it’s work to concentrate in class. So those are the areas we feel. We come
with all those things. You feel like you are subjected to do things. Because
at the moment you call your mama and she tells you all the problem in
Africa. (Mike)
Overcoming Competing Demands Through Optimistic Determination
Participants offered the following comments when discussing how they coped
with competing demands. In most cases, participants turned to internal motivation rather
than reducing the number of hours worked or caregiving responsibilities. The
descriptions that follow demonstrate optimism and determination to finish the nursing
program.
So, you have to see this would be for a limited time. That’s what I used to
say to myself because I’m not going to live this way for the rest of my life.
(Dan)
It was a short time, that was the biggest motivation I had because you
know because I had a lot of friends, I had a lot of coworkers when I was in
[x employer], and then within a short time I graduate and then I became a
nurse, and then “come on man, while we were in coffee house you became
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a nurse” and they were very surprised, they were shocked. You see the
impact from the community. (Dan)
So, that’s when some of the reality came to me. I was like, okay, I’ve done
five years, I was in school, was doing this, helping these people. They are
not being helped. Wherever we didn’t get that like to be helped, I’m sorry.
God help your people. I can do not much, but I gonna pray for them.
That’s the best I can do. Because, I need myself too. (Mike)
One participant identified actions that led to a reduction in competing demands.
Then I spoke with my supervisor. So I told him, don’t give me more than
twenty hours a week. I just want twenty hours. (Dan)
No participants identified specific support systems that assisted in competing demands.
Theme Summary
The third theme, competing priorities, identified heavy financial and family
burdens that participants carried while enrolled in their nursing programs. The effect of
these burdens on their nursing education experience was illuminated through the stories
presented. Participants turned to optimistic determination to cope with competing
demands.
Main Theme: Culture
Culture is defined as “the learned, shared, and transmitted values, beliefs, norms,
and lifeways of a specific individual or group that guide their thinking, decisions, actions,
and patterned ways of living” (Leininger, 2001, p. 95). When sharing their stories,
participants identified a number of cultural elements that influenced their perceptions and
impacted their performance within their nursing education. In addition to specific cultural
practices that participants identified, four sub-themes were identified and include (1)
cultural competency, (2) motivation, (3) view of nursing, and (4) view of education.
These themes and sub-themes are demonstrated in the following excerpts.
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Sub-theme: Cultural competency. Cultural competency is defined as the ability
to function within the cultural context of the beliefs and values of a specific community
(Office of Minority Health, 2013). In the following excerpts, participants describe their
ability to function within the educational environment in which beliefs and values
differed.
I think it was different, and cultural competency, I think, is a big thing for
minorities. Because there are things that are considered taboo: being gay is
taboo for an African. I remember this time when I had just immigrated,
and it was my nursing assistant class, and I was going to Subway. So I’m
walking to Subway and I’m holding this guy’s hand, so the guy gets upset
with me and says, you know you cannot be holding my hand, you cannot
be doing this stuff. So I think there are some things that immigrants need
to learn to become cultural competency and the differentiation between
religion and school, because being brought up in a society where religion
is grilled into you in school. You have a religious class, so religion is
pretty much incorporated in the schools. So things like the nursing home:
from an African perspective, there is no nursing homes. People care for
their parents at home, so there is a lot of things that you get shocked, you
know. Looking you straight in the eye is another thing. From an African
perspective, an older person, you cannot look them straight in the eye.
You need to look down, and that might be viewed from a Western
perspective that you are either lying or you are not being out straight
forward. . . . So I had a tough time with, am I saying the right thing, or am
I not saying the right thing. I am pretty hesitant to speak because I don’t
know if I’m saying the right thing or not. . . . I think it’s just the cultural
aspect of it, that’s the biggest thing I took out of it. Until today I was, I’m
still learning and growing, trying to understand, because sometimes to
somebody like you, it sounds like second nature because you were born
here and you are used to it, so it’s something that you don’t even think of,
it’s subconscious and you just do it. But me, I have to think twice or three
times before I say something or engage something, and if somebody like
what the? I feel like, did I say something wrong, and now I am nervous
that I said something wrong. For example, my first classes, say that
someone would give me a rub and people were laughing in class, and I
was like, oh okay. (Charlie)
We have different culture, you know. As Americans, you are expected to
establish eye contact when talking to somebody, but in our culture you
know, it is a sign of rudeness, you know, if you continuously stare on
somebody. People think that you are disrespecting them or undermining
them if you continuously, but here they misinterpret that as lack of
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confidence, lack of knowledge, you are trying to run away from things you
know. (John)
Sub-theme: Motivation. The sub-theme motivation emerged as participants
shared experiences and circumstances that inspired them to pursue nursing as a career.
This inspiration was a motivational factor in their success. Participants described
previous experiences with an educational system that offered little choice in career path.
As a result, they expressed gratitude in their ability to choose a career that they felt was
their calling.
I wanted to do medicine originally from back home, but I was really a
teenager, you know. You get started in the lifestyle of life, and you start
doing partying all the time, you’re going after girls, it’s just you get
distracted from your view and focus, despite my father wanting us to
become physicians. So I ended up distracting from that goal and doing a
lot of partying. So after I graduated from high school, there the grades, it’s
not like America. There is a national-wide test, and that test determines
whether which career you will go. So my tests weren’t good enough, so I
decided pursuing pharmacy technician, and then we got a lottery visa, so
we came to the United States, but my brother was here before me. . . . So
he is the one who say, you know, okay we’ll do nursing. Nursing is good
because, number one, it’s flexible. You can be able to read, go to school,
and still work. You can go morning, you can go nights, you can even go
PM. So it will introduce you to medicine quickly because you’ll get to see
exactly what was done, and that’s the reason I went and took nursing as
my undergraduate part of medicine. (Charlie)
My passion to be a nurse started a long way back when I had an infection.
. . . So in the process, when you come from a poor family whereby people
are ignorant, they even say that you are bewitched. So I went to the
hospital where nobody understands what is going on, so they kept on just
giving me injections. I don’t know what kind of injections they were
giving me. I remember it was a shot, like, I don’t know. They give me like
around ten shots, and I was ten years old, so I started limping. My leg was
this big. After three months, the small bone just started coming from the
wound. That’s when one of my cousins who lives in Texas, he works in
the operation room. He used to be, like, a sergeant in Africa. Right now he
is just an aid in the operation room. He was the one who came to the
village and was like, why are you doing to this kid, like, this he asked my
dad. My dad told him, I don’t know what to do. So he had to take me from
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the village into the city, where he used to work. That was when I think I
was given Augmentin. I was given an antibiotic, and after a month I was
done. . . . Yeah, I almost lost the leg, because ignorance was contributing
much. Because people don’t know. . . . They don’t understand of the
infection and the sanitary things. So many things are like substandard, not
like there. Small things like mosquitos kills people, malaria kills people.
So that thing inspired me so, like, okay what can I do to help another
person? I would see everything coming from one he comes and washes my
leg, cleans it up, does everything. It inspired me to think like what I need
to do to myself. What can I do to help another person? (Mike)
So when I got here, education in Africa, it is different than it is here. Here
you choose, over there they choose for you. They look at your grades.
They say you are good in business, you are good in math, you need to do
just [marketing]. It’s not your passion. They choose for you, you don’t
choose for yourself, so that’s when you go to the university, give your
grades, and they look at your report, and then they say, okay, you, you’re
good in finance, that’s how they choose. So when I come here, it’s like,
okay, I have the opportunity to do nothing again, okay, I hit the road. I
said okay, I am going to do the exam, do everything. (Mike)
Nursing was my favorite career from the time I was young. Where I come
from malaria is high, it is kind of more. We have seasons from May
through August; it’s always like malaria season. So I was sick and I had
malaria, that typhoid, so I went to the hospital, and I was admitted for
dehydration. And then on the admission I just, you know, I found the
people who were taking care of me were so nice. They were really
concerned about my wellbeing, you know, making sure I’m eating well,
making sure asking me how I’m feeling. That kind of get into my mind
that this looks to be a really nice profession, so after that I decided, I think
when I grow up, I want to become a nurse. The reason why I didn’t kind
of like the doctor part, the doctor would come, assess me, and just go
away. No more questions—do you have pain? Such kind of question. . . .
You know, it was kind of a short stay. But the people spend more time
with were the nurses, so I kind of felt it was important for me to be a nurse
so I can care for people. (Ryan)
When I was in my second year of college, they introduced Bachelor of
Science in nursing, but it was expensive, really expensive for me to go
through, so. When you finish your education in my country, we have
national exams that we do at high school. So and then they select the best
top students, so if it depends. If you have an A you go for medicine. If you
have an A minus you go for the pharmacy. If you have a B plus (that was
the score that I had) you go for things like a Bachelor of Science,
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biochemistry, you become a teacher and stuff. You don’t have too much
choices because that is the way the system is. . . . And I was lucky, they
said I was selected, so when I came here, I was like, RN is what I want to
do, and that is why I started to pursue nursing. (Ryan)
Sub-theme: View of nursing. As participants shared their stories about nursing
education, they also shared a different perspective of nursing practice. This perspective
impacted their understanding of the role of the nurse in the United States. Two
participants described the nurse’s role as more autonomous in their home country.
I felt like, because back in Kenya the nurses do a lot more. They deliver
babies, they do suturing, and it’s more almost like a physician. The
physician is there just to oversee that things are going pretty smoothly. So
the work the nurse does back in Africa is really, really, really intense,
more than the scope of the nurse in America. So I felt, wow, this is going
to be a big undertaking for me as a nurse. Coming to the U.S. and seeing
the scope and seeing the limitations, and there is a lot of limitations, I felt
a nurse in America, it’s a good career, you give a lot of service, but there
is a lot of limitation towards autonomy, which I think it’s good to some
degree, but at least some autonomy needs to be granted to nurses.
(Charlie)
It’s like, you know, it’s quite different. I don’t really know how it is now
over there. I guess I heard that a lot of the schools here now are becoming
sister programs to schools over there. But, like, the nurses in Liberia when
I was growing up, they did a lot more stuff than nurses do here. . . . So
they don’t have a lot of these, like, you know, practice guidelines where,
oh, this nurse’s scope of practice, so you can’t do that. Nurses over in
Liberia, I swear to God, a lot of them are practicing like nurse
practitioners or even MDs. Like, they’re the ones in the communities,
they’re your first line. You’ll see the doctor if the nurse can’t help you.
Right, you know. So, you know, they’re delivering babies. They’re, like,
starting you IVs, you know. I mean, they’re doing like literally everything.
They’re doing like minor procedures and stuff like that . . . Yeah. The
nurses, they run the pharmacy and the neighborhood clinics or whatever. .
. . This is a lot more restricted; I mean, you can get in trouble for saying hi
to someone. (Debra)
Alternatively, two participants described nursing practice that is more complex than in
their homeland.
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And then there is a lot of responsibilities here too. It’s much more
responsibility here than the experience I had before. . . . And in the
community, it’s the same too. I mean, the American community have the
knowledge. They know the medication they need to, you know. . . . So you
have to compete. You have to be more knowledgeable to answer their
questions, so you need more practice and you have to study; otherwise,
even the community will challenge you, because they have basic
knowledge. Even sometimes I learn from the patient. Yeah, it’s true. They
know the medication, they can tell you, okay, how old each is. Yeah, so,
here the standard is different. . . . Yeah. You think, you know, the mindset
is the same; okay nursing is—and then you think the same. And then at the
same time, here, you know, everything is updated. Even this year would
be different compared to next year. (Dan)
If I remained in Kenya and did not come here, I would have still been
nursing in Kenya. It is almost like a totally different profession because
they are seen as doctor’s maid servants. It’s not really deemed and given
the esteem as it is here in this country, but I would have still done nursing.
(Emma)
Sub-theme: View of education. When discussing their nursing education
experience, participants offered examples of how education in their African homeland
differed from education in the United States. These differences had an effect on the
expectations that participants had for their nursing education. The following excerpts
were offered by participants in relation to their view of education.
In America, people are gauged based on, I know the answer. The more
questions you answer, the more intelligent you look, and the more smarter
you look, and the better you look, like, you know, you’re answering
questions and you know more. But being raised in a society where you are
told, you know, you have to be polite, you cannot be talking in front of
your elders, so we are not gauged on participation, so you have to force
yourself, you know, to answer questions. You are trying to compete with
what you are taught not to do, so that’s another thing that I struggled with,
is trying to be out there, trying to answer questions, trying to be, to fight to
be . . . (Charlie)
Oh, and then the educational system, the schooling system we have in our
country, it doesn’t fit with the American because we were more relaxed
there. You are more relaxed, you have enough time. Sometimes you don’t
work, you just go to school and then enjoy. But here there is a lot of
challenge. You have to live too. (Dan)
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Especially when you were born in a village whereby education is not fast,
like the one in the [Xtown]. You have a big challenge to jump. So for me,
that was the case because I was not teached in the city. I was raised in the
village. (Mike)
Actually, I did know, it was lack of, you know when you are doing bad,
you don’t want to be messing up with your grades. I didn’t know how to
withdraw from a class. So I think Africa, where we come from, there’s one
thing we lack. We lack to read instructions. I tell you, you be an instructor
for a student from Africa, and um, that was one of the easiest thing which
fails most African people. We don’t read the instructions. Because we are
not polished into reading instructions. You are given a paper, you are told
it is essay just write what you know, and you are done. So I think, I went
through an orientation, but some of the things were new. What’s to
withdraw? So, like, they said they set deadlines for withdrawing classes, I
didn’t know what it was. (Mike)
Coming from Africa, you know, I probably appreciated this more than my
other classmates because, you know, I understand that, like, high school
and grade school education here in America you kind of, like, you do it if
you want to, and then you know everybody gets moved ahead. It’s not like
that in Africa. It’s like totally authoritarian. You are the student, that’s the
teacher, the teacher tells you what to do, you will do what the teacher says,
and if you don’t do what the teacher says, you are out of here. And if you
don’t make the passing score, you’re out of here. You don’t get to go
forward until you pass. (Debra)
In Africa, there are three things. In Africa, there are classes. Classes of
people. Royal family, when you’re poor, you’re poor. There’s no middle
class. That when changes. Right now me and you, your college professor.
I’m a student. We can’t have this conversation in Africa. I could meet
three secretaries before I meet you. And I couldn’t have this time that you
are interviewing me for one hour. (Mike)
Participants with a nursing or medical background discussed how their expectations for
nursing education differed from their actual experience.
I had a nursing degree. I mean, even I was trying to be certified as a nurse
with the associate degree, however, you know, they asked me to bring
license and work experience, even the practice I did in back home wasn’t
enough to qualify for an associate degree in the United States, especially
psychiatric and in other requirements. So, yeah, and then I decided to start
from the beginning. . . . You know, nursing is pretty much the same, but at
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the same time it is not the same. There is the public view of nursing and
the teaching system of nursing. For example, when I was in back home,
we had limited in theory content compared to the clinical practice. . . .
Even when I was in Europe,you practice a lot. In the European union, they
have the same teaching style. You have to spend a lot, a lot in clinical
practice. . . . And then here clinical practice is very, very limited. It’s very
short and then you have a lot of things to do at the same time. You have a
lot of assignments—there is a quiz, you are always overwhelmed. You are
always on the go, busy, and then you have to catch, you know, you have to
catch with the schedule. Sometimes, you know, I don’t see even what we
have and then. . . . So it’s a little bit busy, and then it is more focused on
theory. (Dan)
We knew, like, in just going to the high school over there, I think I was
way advanced when it came to the sciences, and, you know, math and that
kind of stuff compared to the American students here. Because coming
here and they’re like, oh you have to take biology, microbiology, and
anatomy and physiology before you go to the nursing program. Whereas
my stepmom was struggling through those classes, I kind of breezed
through it. . . . And I’m like, what you’re calling microbiology here, that’s
tenth grade biology where I come from. . . . And your general biology,
that’s what they do in seventh grade where I come from. You know, and
the chemistry and the anatomy and physiology, we do this stuff in ninth
and tenth grade. So by the time I get to the twelfth grade, I am doing stuff
that your freshman and, you know, sophomore college students do here.
(Debra)
I expected to be exposed more to this environment that I’m going to be
working in. In Kenya, the exposure is a lot because I guess, you know,
because the healthcare system is different, and the resources are more in
terms of exposure to actual clinical setting and clinical work. (Emma)
Overcoming Cultural Barriers Through Optimistic Determination
Statements for overcoming cultural barriers were imbedded in previous
comments. Participants overcame these barriers through an internal desire to learn the
culture and be successful. The following statements demonstrate optimistic determination
as they relate to culture:
You know, and I was just like, oh my God, thank you; you know, God
Bless America, this is really you know, the country of opportunity. This
would never happen in Africa, you know. (Debra)
I entered the class not with 0% working my way to 100%, but I entered
with 100%, and if anything happened it would subtract, so kind of having
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an optimistic perspective of my teachers, even if I was from a different
culture, different accent, different everything. . . . I kept reminding myself
nothing is permanent, nothing is permanent. . . . So I would say that was a
point where I was discouraged in terms of you know, think big, think
outside the box, and I made up my mind. (Emma)
And that is why I was like, I am not going to be discouraged. I’ll fight on.
It was more you become discouraged, and then you have to look the
reason why you came to the problem in the first place. And then I always
say to myself, anything that doesn’t kill you will make you strong, and for
sure I know it wasn’t going to kill me, so it was going to make me strong,
and the only way I could find my strong points were to lean on or to see in
one person who doesn’t like me, what about the other people. So I found
that the people are kind of more receptive, willing to help me, so it was a
time, it was only a season that’s going to pass. I realize after that I was
going to be fine. (Ryan)
Theme Summary
The theme culture described how different beliefs, values, and experiences
influenced the participants’ nursing education experience. Excerpts were provided to
illuminate the sub-themes of cultural competency, motivation, view of nursing, and view
of education. Participants overcame challenges relating to culture through optimistic
determination
Chapter Summary
The lived experience of black African nurses educated within the United States
was explained in four main themes of academics, relationships, competing demands, and
culture. An additional 13 sub-themes were included within the descriptions. The essence
of optimistic determination was demonstrated throughout the participants’ statements.
Combined, the essence, themes, and sub-themes provided an exhaustive description of
the lived experience of black African nurses educated within the United States.
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CHAPTER VI
DISCUSSION AND INTERPRETATION
The purpose of this phenomenological inquiry was to gain an understanding of
how black African nurses experience nursing education within the United States.
Through this research study, four main themes with 13 sub-themes revealed “optimistic
determination” as the overall essence of the participants’ experiences. This chapter
provides an interpretation of findings as they relate to the current literature and makes
recommendations that guide nursing programs toward a culturally competent educational
environment.
Findings as They Relate to the Current Literature
Despite the unprecedented growth of minority populations in the United States,
the nursing profession has remained relatively homogenous. Nursing education has
increased the number of minority students entering nursing programs. However, attrition
rates for minority nursing students continue to be high. As the population grows in
diversity, the need for nurses fluent in foreign languages and who understand minority
values, traditions, and cultural practices will be essential in delivering culturally
competent care. Improving the retention of minority nursing students is an important step
in increasing the diversity of the nursing workforce.
Although several studies have identified barriers and challenges of minority
students, few have addressed retention from an individual minority standpoint. Cultural
competence in education requires that the unique characteristics of individuals’ values
and beliefs be considered. Black Africans are among the fastest growing immigrant and
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refugee populations in the United States, and literature relating to their experiences in
nursing education in the United States is scarce.
The results of this study are unique. Through a review of the literature, this
researcher was able to identify only one other published study related to nursing
education that was restricted to a black African population. In some respects, one could
say that this study builds on the findings of Sanner et al. (2002) by improving the
generalizability of findings. Sanner et al. (2002) studied eight female Nigerian nursing
students to determine how international students describe their experience in a single
United States baccalaureate nursing program. In contrast, the participants in this study
were both male and female, originated from various African countries, and were
graduates of varying baccalaureate and associated degree nursing programs within the
upper Midwest. Additionally, all study participants within this study were currently
working as registered nurses, whereas the participants studied by Sanner et al. (2002)
were recruited after successfully completing two nursing courses. Table 1 (appendix H)
provides a comparison between this study and the 2002 study conducted by Sanner et al.
This author could find no other published studies that included a sample of
exclusively black African nursing students. Therefore, findings from this study are also
compared to studies relating to English-as-a-second-language (ESL), English-as-an-
additional-language (EAL), and minority nursing students. Although many of these
studies include black African participants, comparisons should be interpreted with
caution. Some of the participants of this study did not identify themselves as ESL or EAL
students because their primary language was English. Additionally, findings from the
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comparison studies often included other minorities that likely influenced data through
differences in cultural beliefs, values, and practices.
Overall Essence: Optimistic Determination
Optimistic determination was found to be the overall essence of the experience for
participants in this study. When challenges in academics, relationships, culture, or
competing demands arose, it was the participants’ optimistic determination that helped
them to succeed and accomplish their goals. Several studies relating to minority and ESL
students confirm these findings.
Merriam-Webster Dictionaries (n.d.) defines determination as the firm or fixed
intention to achieve a desired end. Batykefer-Evans (2013) studied the influence of non-
cognitive variables on the intention of baccalaureate nursing students to complete their
program of study. Minority students scored higher on their level of intention than non-
minority students (Batykefer-Evans, 2013). Minority and ESL students persisted despite
obstacles (Amaro et al., 2006; Sanner, 2002), and were described as self-motivated,
optimistic, and determined (Amaro, Abriam-Yago, & Yoder, 2006; Mulready-Shick,
2013; Napierkowski & Pacquiao, 2010; Sanner et al., 2002; Starr, 2009).
The literature supports the findings from this study and suggest that optimistic
determination is major factor in the success of black African nursing students.
Self-Efficacy as It Relates to Optimistic Determination
A primary focus of Bandura’s social cognitive theory is self-efficacy. Bandura
(1997) defines self-efficacy as an individual’s belief in his or her ability to succeed in a
particular situation. Concepts of self-efficacy are found within the definitions of
optimism and determination. This researcher has chosen to use the terms used by
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participants to identify the essence of the phenomenon. However, given the similarity in
definitions, Bandura’s (1997) theory of cognitive development is ideal for determining
the origin of the participants’ optimistic determination. Bandura (1997) proposed four
sources of self-efficacy: enactive mastery experience, vicarious experiences, verbal
persuasions, and physiological and affective states. Each source is discussed as it relates
to the participants’ experiences.
Enactive Mastery Experience. According to Bandura (1997), the mastery of
experiences effects how individuals perceive new challenges. Mastery strengthens one’s
belief that he or she can be successful, while failures undermine this belief. With that
said, individuals must experience some hardship in order to develop resiliency.
According to Bandura (1997), “a resilient sense of efficacy requires overcoming
obstacles through perseverant effort” (p. 80). Many of the participants in this study
shared stories of overcoming obstacles related to finances, living conditions, and
education in their African homeland and the United States. According to Bandura (1997),
this mastery assisted in the development of self-efficacy. As a result, students displayed
optimism and determination in the face of challenges that they encountered in their
nursing education.
Vicarious Experiences. The second source of self-efficacy, according to Bandura
(1997), is vicarious experiences: “Modeling serves as an effective tool for promoting a
sense of self-efficacy” (p. 86). When black African students see other black African and
minority students succeed in nursing education, they are inspired and encouraged.
Several participants discussed role models that were influential in their nursing education.
Modeling was an important influence in participants’ sense of optimistic determination.
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According to Bandura (1997), “seeing or visualizing people similar to oneself perform
successfully typically raises self-efficacy beliefs in observers that they possess the
capabilities to master comparable activities” (p. 87). While discussing role models,
participants identified with a similarity, whether it was gender, race, or ethnic
background.
Verbal Persuasion. Bandura (1997) identified the third source of self-efficacy as
verbal persuasion. Verbal persuasion involves receiving positive reinforcement that helps
an individual overcome self-doubt. Bandura (1997) stated, “People who are persuaded
verbally that they possess the capabilities to master given tasks are likely to mobilize
greater effort and sustain it than if they harbor self-doubts and dwell on personal
deficiencies when difficulties arise” (p. 101). Most participants spoke of a particular
faculty member, employer, peer, or family member that provided positive reinforcement.
This reinforcement strengthened participants’ optimistic determination.
Physiological and Affective States. The fourth and final source of self-efficacy
identified by Bandura (1997) is physiological and affective states. An individual’s
physiological state impacts their perception of the situation and their ability to achieve a
desired goal (Bandura, 1997). For example, a nursing student who becomes extremely
agitated while inserting an IV may develop a weak sense of self-efficacy in future
situations involving IV insertions. Although this type of response diminishes an
individual’s self-efficacy, the ability to effectively recover from stressful events can have
the opposite effect (Bandura, 1997). This ability to mediate stressors implies that black
African nursing students’ physiological responses to earlier experiences impacted their
perception of their ability to overcome obstacles. Participants of this study identified
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stressful experiences with health, relationships, and education in their African homeland.
The effective mediation of these stressors contributed to the students’ optimistic
determination.
Theme One: Academics
As participants discussed their experiences with nursing education, topics relating
to academic performance emerged within the theme “academics.” Participants discussed
aspects of testing, language, and technology. Although a search of the literature
pertaining to African-born nursing students provided no results for the aforementioned
sub-themes, the search did reveal a number of articles in relation to ESL and minority
students. Findings from this study are consistent with this literature.
Language. When discussing academics, participants of this study identified the
need to translate and process content into their native language in order to clearly
understand concepts. This is consistent with several authors who have identified ESL and
minority students’ need for extra time for translation as a barrier for minority and ESL
students (Caputi, Engelmann, & Stasinopoulus, 2006; Chiang, 2009; Olson, 2012; Starr,
2009;). Choi (2005) applied the Cummins model of language acquisition to ESL nursing
students in order to explain this process. According to the Cummins model, language
acquisition occurs in two stages. The first stage is identified as basic interpersonal
communication skills (BICS), while the second stage is described as cognitive academic
language proficiency (CALP; Cummins, 1983). In order to facilitate the transition from
BICS to CALP, it is important for nursing students to explain nursing concepts in their
native language, in addition to communicating them in English (Choi, 2005). This
translation is an extra step for ESL and minority students and as such takes extra time.
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In addition to the need for additional time, participants of this study identified
difficulty with understanding slang words and other terms that were unique to the day-to-
day English of the United States. Literature concerning ESL students reported similar
difficulties (Bosher, 2009; Caputi et al., 2006; Wessling, 2003). In one example, a
Hispanic student explained that the problem in testing was not due to the medical
terminology or the concept, rather with the day-to-day English (Wessling, 2003).
Testing. Multiple-choice testing is the gold standard in nursing education and is
the format of the national RN licensing exam. Participants of this study expressed
difficulty with a multiple-choice format of assessment. This finding is consistent with the
findings of previous studies. Multiple-choice testing was identified as a barrier by several
authors (Bosher & Bowles, 2008; Brown, 2008; Caputi et al., 2006; Fernea, Gaines,
Brathwaite, & Abdur-Rahman, 1994; Napierkowski & Pacquiao, 2010; Starr 2009). In
some cases, participants identified the format of multiple-choice testing as new to them
and described the use of essay and fill-in-the-blank as the sole means of assessment in
their native country. This finding is consistent with the findings of authors studying ESL
student barriers (Fernea et al., 1994; Napierkowski & Pacquiao, 2010). In addition to the
format of testing, the participants in this study voiced difficulty with the critical thinking
skills necessary to be successful on exams. Napierkowski and Pacquiao (2010) reported
that students who had experience studying internationally were experienced in the
memorization of facts. In addition, a meta-synthesis performed by Starr (2009) revealed
that EAL students spend more time on “memorization of facts rather than on
understanding concepts and abstractions” (p. 483).
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The final area of difficulty in testing relates to bias. Klisch (1994) defines test-item
bias as “test items that are slanted toward a specific group, and as a result discriminate
against another group of examinees” (p. 36). Participants in this study identified specific
examples where test items were slanted toward American culture. This type of bias is
also referred to as cultural bias (Bosher, 2009). Bosher (2009) identified two additional
areas of linguistic difficulties for ESL students. These difficulties are described as
irrelevant difficulty, and linguistic/structural bias (Bosher, 2009).
Irrelevant difficulty relates to flaws in test items that are unrelated to content or
the focus of the exam (Bosher, 2009). An example of irrelevant difficulty is a test item
that requires the test-taker to complete the sentence. Other examples include those test
items that include double negatives or best answer questions that use descriptive terms
such as least or most. In a review of 73 test questions from a nursing textbook publisher’s
test bank, Lampe and Tsaouse (2010) found that all items demonstrated flaws in
irrelevant difficulty. Irrelevant difficulty is problematic for all students because it requires
an additional amount of time for the student to determine what the question is asking. For
ESL students, irrelevant difficulty is an added burden because, as discussed, they already
need additional time to translate materials into their native language.
Linguistic/structural bias refers to unnecessary complexity in the stem or options
within the exam question (Bosher, 2009). Two forms of linguistic/structural bias are
embedded and reduced clauses, and unclear wording (Bosher, 2009). Embedded and
reduced clauses can be described as run-on sentences with multiple ideas within one
sentence. Unclear wording is described as uncommon terminology (Lampe & Tsaouse,
2010). As with irrelevant difficulty, questions with linguistic and structural bias require
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extra time for students to understand what the question is asking. ESL students have the
added challenge of translating these questions into their own language and are therefore
stressed to complete these questions in the time allotted (Lampe & Tsaouse, 2010).
Technology. Technology was identified as the third and final sub-theme under
academics. A few participants discussed an unfamiliarity and lack of experience with
technology as a barrier to their nursing education success. Although institutional support
was provided to learn the technology, speed was a factor in the ability to use the
technology efficiently. Participants felt that American students had an advantage over
them in terms of early exposure and years of practice. This is a new finding that is
undocumented in the nursing literature. As the use of technology in nursing education
increases, this is an area that may require further investigation.
Theme Two: Relationships
Participants within this study felt that relationships were an important part of the
nursing education experience. When discussing relationships, participants told stories
relating to faculty, classmates, and patients within the clinical setting. Relationships were
described as both positive and negative. In all cases, language had a significant impact on
the development of relationships.
Language. Previous studies have revealed language differences as the primary
source of discrimination (Amaro et al., 2006; Gardner, 2005; Sanner et al., 2002).
Participants in this study described feeling devalued and misunderstood as a result of
their thick accents. Similar to findings from this study, Sanner et al. (2002) reported that
participants felt that they were perceived as unintelligent and of no value in group
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participation as a result of their strong accents. Mulready-Shick (2013) also reported that
participants felt unappreciated and de-valued due the accent and language differences.
Faculty. The importance of student-faculty relationships in education has been
studied extensively. It is well known that supportive relationships between faculty and
students improve student retention and success. This is not a finding that is unique to
black African nurses and applies to all nursing students regardless of ethnic or racial
background (Cho & Auger, 2013; McEnroe-Petitte, 2011; Shelton, 2003). Although some
participants of this study experienced discrimination at times, all valued their
relationships with faculty and identified supportive faculty relationships as a contributing
factor in both their motivation and success. These findings are consistent with the current
literature (Amaro et al., 2006; Gardner, 2005; Starr, 2009).
When describing supportive faculty, most participants in these studies identified a
specific faculty member that showed a particular interest in them, demonstrated caring
behaviors, and/or accommodated their unique cultural needs or differences. Gardner
(2005) reported that supportive faculty were described by participants as those who took
an interest in, provided emotional support for, and treated them as individuals with
unique needs. Similarly, Starr (2009) described supportive faculty as those who reach
out, listen, and respect cultural differences. Similar to this study, participants of Amaro et
al. (2006) described one particular faculty member that reached out to them and made a
difference.
Although all participants in this study found support, motivation, and inspiration
within their nursing faculty, a few participants experienced discrimination. Participants
reported being passed over during class discussion and questioning. Additionally, some
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participants felt that some nursing faculty were unapproachable and unwilling to
accommodate cultural needs and differences. The meta-synthesis performed by Starr
(2009) identified instances of discrimination and insensitivity from faculty. The findings
from Wong, Seago, Keane, and Grumbach (2008) also support this finding. Authors
reported that African American students had less interaction with faculty compared to
other racial and ethnic groups. However, this comparison should be made with caution
because it is unclear from the sample description whether the category of African
American was inclusive of black African students or whether they were native to the
United States.
Classmates. Similar to faculty relationships, participants of this study described
relationships with peers as both positive and negative. Many participants encountered
support both academically and socially from students within and without similar ethnic
and racial lines. Amaro et al. (2006) described peer support as a “major pillar” of support
for minority students (p. 252). Participants of this study provided a similar description of
support in terms of study groups. Fernea et al. (1994) concluded that minority students
prefer to study in groups. Mulready-Shick (2013) found that minority students focused on
the establishment of relationships with peers as a response to feeling segregated or
isolated. Although participants of this study worked hard to establish relationships, they
often formed relationships with students of the same ethnic and racial background when
they felt isolated. Several authors described negative interactions with peers as primarily
a result of the language difficulties, as previously discussed (Amaro et al., 2006; Gardner,
2005; Mulready-Shick, 2013; Napierkowski & Pacquiao, 2013; Sanner et al., 2002; Starr
2009; Wong et al., 2008).
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Clinical: Patients and Classmates. The final sub-theme of relationships
discusses by participants pertained to clinical experiences. Participants described
examples of patients who refused their care based on their racial background and
language differences. Amaro et al. (2006) identified similar findings and stated that
discrimination happened most frequently in the clinical setting. Although the participants
of this study identified discrimination only in the form of patient interactions, the
participants of the Amaro et al. (2006) study described unfavorable interactions with
clinical staff and patients. Relationships with peers in the clinical setting were described
in a more positive light both within this study and within the literature. The small-group
nature of the clinical setting created an atmosphere of dependability among peers. As a
result, participants of this study identified stronger peer relationships within the clinical
setting. A student in Sanner et al. (2003) was quoted as saying, “It’s different when we
are in clinical, we have to work together as a team” (p. 210).
Relationships are an important part of the lived experience for black African
nursing students. Language plays a role in the development of relationships with faculty,
peers, patients, and clinical staff. Although some participants described negative aspects
of relationships, all found support from their peers and/or faculty. The evidence provided
suggests that these findings are consistent with the current literature relating to minority
and ESL nursing students.
Theme Three: Competing Demands
The third theme, competing demands, emerged while students were discussing
aspects of their lives that competed with the time and attention needed for studying.
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Participants spoke of work and family responsibilities. A search of the literature relating
to ESL and minority nursing students produced similar findings.
Work. Nearly all of the participants in this study reported working at least part
time while enrolled in their nursing program. Participants cited family obligations and
living expenses as a basis for this decision. The studies relating to minority and ESL
students reported similar findings. In general, minority and ESL students work while
enrolled in academic programs and perceive this as a stressor on their academic progress
(Amaro et al., 2006; Fernea et al., 1994; Mulready-Shick, 2013; Napierkowski &
Pacquiao, 2010; Starr, 2009). In all cases, researchers identified family obligations and
personal support as the motivating factor behind students’ decision to work. Participants
of this study provided a third rationale for working. Many participants voiced concern
about taking out student loans and voiced a need to remain debt free. Although no
studies reported this specific rationale for working, Starr (2009) concluded that minority
and ESL students have a lack of financial aid. It could be assumed that a lack of financial
aid would require students to take out loans. The fact that most ESL students are working
at least part time provides support to the findings that this student population is not taking
out loans to support an education.
Family responsibilities. Participants of this study discussed the burden of
financially supporting family in their homeland. Mulready-Shick (2013) identified
familial responsibility in participants’ homeland as a stressor for ESL students.
Napierkowski & Pacquiao (2010) reported similar findings. Additionally, participants of
this study discussed the struggle of providing support for their family and children here in
the United States. Amaro et al. (2006) reported that minority students continued to carry
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most or all of the financial and care-giving responsibilities of the family. The meta-
analysis performed by Starr (2009) concluded that many participants were single parents
supporting other members of their family. Although no participants in this study
identified themselves as single parents, many spoke of the expectation to care for family,
both emotionally and financially, back in Africa.
Although many participants of this study spoke of family and work as a stressor,
some denied that these factors were competing demands in their education. A few
participants indicated that spouses took on more financial and care-giving responsibility
in order to provide them with the time necessary to be successful in their nursing
program. In addition, one participant reported that family members in Africa supported
some of the participant’s costs of education and living. Amaro et al. (2006) was the only
author with similar findings and reported that some participants received financial and
emotional support from family that helped to lessen competing demands.
ESL, minority, and black African nursing students have considerable stressors as
a result of family and financial obligations. These stressors have an impact on the
performance and success of this population in nursing education. Although some students
receive support from spouses and family members, the majority balance the demands of
being a provider and student. The results of this study are consistent with the literature.
Theme Four: Culture
While discussing their lived experience of nursing education, participants shared a
number of cultural considerations that had both positive and negative effects on their
progress and performance. Culture is defined as “the learned, shared and transmitted
values, beliefs, norms and life way practices of a particular group that guide thinking,
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decisions, and actions in patterned ways” (Leininger, 2001, p. 95). Participants of this
study identified a number of cultural elements that influenced their perception and
performance within their nursing education. In addition to specific cultural experiences,
beliefs and practices influenced their motivation, their understanding of nursing as a
profession, and their view of education.
Cultural competency. Participants of this study identified culture as the basis for
fear in speaking up in class. In addition, respect for authority prevented participants from
maintaining eye contact, reaching out to faculty, and being assertive in the classroom.
Literature relating to minority and ESL students supported these findings (Amaro et al.,
2006; Starr, 2009). Additionally, participants of this study discussed needing assistance
navigating the educational systems in terms of applying for financial aid, withdrawing
from classes, and meeting program requirements. The current literature supports the need
for orientation and mentoring related to the education system (Starr, 2009).
Participants of this study discussed instances where culture influence how they
acted in patient situations, and their understanding of nursing concepts, such as
therapeutic communication, obstetrics, and mental health. In a meta-analysis, Starr (2009)
concluded that culture can influence what a student learns and how a student perceives
the information. In a systematic review of the literature, Olson (2012) concluded that
“therapeutic communication is culture bound and requires the student to firmly
understand American mainstream culture and terminology” (p. 30).
Motivation. Although there were similarities relating to the discussion of culture,
there were several findings from this study that were undocumented in the literature
pertaining to minority and ESL students. First, participants of this study discussed a rigid
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educational system in their African homeland. This rigidity offered participants little
choice in their career path. Participants were grateful for the opportunity to have a choice
to pursue nursing in the United States. This freedom provided them with motivation and
inspiration.
View of Nursing. Second, participants of this study discussed how nursing
practices in their African homeland differed from the practice requirements they have
experienced in the United States. Some participants experienced a much more
autonomous environment in Africa, with a scope of practice that was non-existent. Others
described the African nurse in a subordinate role with little responsibility. In either case,
these cultural experiences impacted the participants’ understanding of the role of the
registered nurse in the United States.
View of Education. Finally, participants discussed how their expectations for
their nursing education differed from their actual experience. Participants of this study
expected their education to focus more on physiological concepts, provide more clinical
time, and include advanced concepts in the sciences. These viewpoints were the result of
previous educational experiences in their homeland.
Participants identified a number of examples of how culture plays a role in the
nursing education experience. Some of the aspects of culture were documented in the
literature pertaining to minority and ESL nursing students. However, several aspects of
the participants experience were unique to black African nursing students and were new
findings.
Implications for Nursing
108
The findings of this study offer several implications for the discipline of nursing.
First, the research findings contribute to the science of nursing education by offering
nursing faculty, nursing students, and researchers a better of understanding of how black
African students experience nursing education. It is especially important for faculty to
recognize and appreciate the cultural differences of the black African student in order to
provide a supportive and inclusive classroom environment. Leininger’s (2001) theory of
nursing provides a framework for the development of culturally competent nursing
education practices. Leininger (2001) proposed that nursing care can be improved by
considering the patient’s culture. This recognition decreases stress and promotes recovery
(Leininger, 2001). When translating this concept to the nursing classroom, it can be
assumed that nursing education can also be improved by considering the student’s
culture. The literature and the findings of this study have demonstrated clearly that
relationships with faculty are an important part of the education experience for black
African nursing students. Leininger (2001) identified the need to recognize the fact that
an individual’s culture affects the nurse-patient relationship (Sitzman & Eichelberger,
2011). The same could be said for the faculty-student relationship. In many cases,
participants identified supportive faculty as those who took a personal interest in them
and their cultural differences. Several studies support this finding (Amaro et al., 2006;
Batykefer-Evans, 2013 Gardner, 2005; Napierkowski and Pacquiao, 2010; Olson, 2012;
Starr, 2009). Faculty need to reach out and take an interest in the black African student in
order to form strong, supportive, and caring relationships. Reaching out includes very
clearly asking black African students what their cultural experiences and preferences are
in relation to education (Sitzman & Eichelberger, 2011).
109
Second, Leininger (as cited in Sizman & Eichelberger, 2011) described the
culturally competent nurse as one who “incorporates the client’s personal, social,
environmental, and cultural needs and beliefs into the plan of care whenever possible” (p.
97). Therefore, the culturally competent educator needs to do the same when planning
learning actitivies for the black African student. Yoder (1996) identified five patterns of
responding to ethnically diverse students that run along a continuum of low to high
cultural awareness. In the first pattern, the generic pattern, educators work from a non-
existent appreciation of cultural diverseity and deny that ethnicity influences the
educational process. In the second pattern, mainstreaming, faculty are culturally aware
but attribute the problems of ethnically diverse students to the student’s knowledge
deficit related to the dominant culture. In the mainstreaming pattern, faculty force the
student to conform. In the third pattern, non-tolerant, the educator creates barriers for
minority students by being unwilling to tolerate cultural differences. In the fourth
approach, the struggling pattern, educators recognize the cultural differences and attempt
but struggle to find ways to adapt to individual needs. They have moved from a lower to
higher cultural-awareness level. In the fifth and final response pattern, bridging, faculty
display a high level of cultural awarenes and value diversity. They encourage students to
“maintain their ethnic identify and function biculturally” (Yoder, 1996, p. 6).
A bridging faculty makes adjustments to meet students’ cultural needs and does
not force the student to conform to the norms of the educational environment. In terms of
the black African nursing students, this could mean possibly providing additional time for
the translation of course content and exams, facilitating language development, providing
advisement within the academic environment, and demonstrating caring and flexibility in
110
terms of family commitment and responsibilities. Although it is a natural tendency of a
nurse to want to “fix” every situation, the findings from this study indicate that the most
powerful contributor to the participant’s success comes from within.
The overall essence of the participants’ experience was optimistic determination.
Using Bandura’s (1997) model of social cognitive develop, nursing educators can aid in
the development of optimistic determination by reaching out to students and providing
encouragement. Providing the black African student with a peer mentor of similar racial
and ethnic background can establish modeling. Interventions that promote faculty
relationships, boost self-confidence, and provide inspiration are likely to see the most
favorable results.
Limitations
Participants in this study attended nursing programs in the upper Midwest.
Therefore, results of this study may not be generalized to all regions of the country. In
addition, not all African countries were represented in this study. Therefore, it is possible
that nursing students from other African countries may provide different perspectives and
experiences.
Recommendations for Further Research
Max van Manen (2007) described phenomenology as a method that “opens up
possibilities for creating formative relations between being and acting” (p. 13). It is the
hope of this researcher that findings from this research open up possibilities for
implementing culturally competent care in the nursing classroom. Further studies are
needed to explore the effects that the above-mentioned interventions have on the
retention and success of black African nursing students. Further, because the results of
111
this study are an interpretation of this researcher, replication studies are important. It is
this researcher’s hope that this study is replicated with black African nurses in other parts
of the United States, and that study samples are representative of all sub-Saharan African
countries. Finally, because this study provided results that were unique to the black
African population, it is this researcher’s hope that future studies are conducted into the
needs of other minority students so that culturally competent education can become a
reality.
Chapter Summary
This chapter provided a discussion of the findings in relation to the current
literature. Although literature pertaining to minority and ESL nursing students supported
many of the findings, new findings unique to black African nursing students were
presented. Included in the discussion were implications for nursing education, limitations,
and recommendations for further research.
CONCLUSION
The purpose of this study was to determine how black African nurses experience
nursing education within the United States. Nine participants volunteered to share their
stories. Together, their stories resulted in the identification of four themes and 13 sub-
themes that contribute to a rich description of the phenomenon. The essence of the
phenomenon was optimistic determination. Participant validation provided evidence that
the interpretation of the phenomenon was accurate. Understanding how black African
nurses experience nursing education in the United States has implications for nursing
education. This study provided evidence that black African nursing students have unique
112
needs. Because culturally competent nursing education has the ability to improve
educational outcomes, faculty have a duty to recognize and accommodate these cultural
differences to the best of their ability. Through this awareness, gains in the retention of
black African nursing students, and a growth in nursing workforce diversity can be
realized.
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APPENDICES
APPENDIX A
SUMMARY OF LITERATURE
Reference
Description of Study Results/Conclusion
REVIEW OF LITERATURE RELATED TO BLACK AFRICAN NURSES
EDUCATED WITHIN THE UNITED STATES
Black African Migration
Migration Policy Institute,
2011
Expository
Presents current information
related to migration patterns
for black African
immigrants; data related to
employment, education, and
health status of immigrants.
Remington, 2008
(Institute for Agriculture
and Trade Policy)
Expository Presents data and general
information related to
African immigrants living in
Minnesota.
Terrazas, 2009 Expository Presents data and general
information related to
African immigrants in the
United States.
Workforce and
Educational Diversity
American Association of
Colleges of Nursing, 2011
Expository Identifies the need to
increase diversity as a
priority for the profession of
nursing in the United States.
Brown & Marshall, 2008 Expository article Identifies retention
strategies for minority
students. Strategies include
mentoring, academic
support, cultural competence
education. Two years into
implementation, the
program has identified an
increased enrollment,
retention, success, and
cultural competence.
Escallier & Fullerton, 2009 Expository article Presents a review of
literature related to retention
114
strategies for diverse
nursing students. Discusses
the use of cultural
competence in teaching,
mentorship, and technology
support to increase retention
at Stony Brook University,
Long Island, NY. Only
slight improvements to
retention were made and
could not be attributed to the
intervention strategies
described.
Evans, 2007 Descriptive non-
experimental design to
identify student perception
of the influence of a
workforce diversity grant on
retention. Questionnaires
completed by 15
Hispanic/Latino and
American Indian students
Found participants identified
feelings of isolation despite
receiving grant services and
support. Participants
regularly cared for patients
from their own cultural
background. Grant services
were successful in boosting
self-confidence of students.
Grant services included
mentoring, tutoring,
financial support,
counseling, and
development of pipeline by
recruitment at the middle-
school level.
Gilchrist & Rector, 2007 Literature review Concluded that a diverse
nursing workforce is needed
to address current health
disparities within the U.S.
Nursing programs must
attract and support diverse
students in order to build a
diverse nursing workforce.
Strategies for retention
include tutoring, stipends,
diversifying curriculum,
aiding in time management,
mentoring, and the early
identification of problems.
National Advisory Council
on Nurse Education and
Practice, 2001
Report Reports on the need for
diversity to reduce health
disparity and provide
115
culturally competent care.
Provides statics relating to
disparity in the nursing
workforce.
National League for
Nursing, 2012
Expository summary of
findings from annual survey
of schools of nursing 2010–
2011
Provides current enrollment
data related to racial-ethnic
minorities.
Noone, 2008 Literature review Addresses lack of diversity
in the nursing workforce
within the United States. A
comprehensive approach is
most often used for
recruitment and retention of
diverse students.
Sanner, Wilson, & Samson,
2002
Qualitative study to explore
the perceptions and
experiences of eight female
Nigerian students enrolled
in a baccalaureate nursing
program
Identifies three themes:
social isolation, resolved
attitudes, and persistence
despite perceived obstacles.
Perceptions indicated that
isolation was the result of
not being American and the
presence of foreign accent
and difficulties
understanding language and
expressing oneself.
The Sullivan Commission,
2004
Expository Provides data and
conclusions regarding
minorities within the
healthcare workforce.
The United States
Department of Health and
Human Services, 2010
Non-experimental
descriptive survey of 33,549
RNs employed within the
United States
Provides information related
to current racial/ethnic
demographics of the RN
workforce, RN graduates,
and nursing student
populations.
Wilson, Andrews, &
Leners, 2006
Literature review Addresses diversity trends
within the United States,
nursing profession, and
educational setting.
Mentoring is found to be a
valid strategy to retain
diverse populations.
Wilson, Sanner, &
McAllister, 2010
A focus group methodology
was used to evaluate
perceptions of faculty a
Identifies three faculty
themes: role modeling,
caring, and academic
116
faculty mentoring program;
the study sample consisted
of 10 faculty mentors and
10 student mentees from
disadvantaged backgrounds
success. Three student
themes identified were
support system, enhanced
perception of the nursing
profession, and academic
enrichment. Results
supported the need to
mentor disadvantaged
students in programs of
nursing.
African Immigrant
Health Beliefs and
Practices
Adepoju, 2012
Qualitative micro-
ethnographic study of the
health beliefs and practices
of Yoruba immigrants
living in the United States;
13 males and three females
participated in face-to-face
and phone interviews
Concludes immigrants use a
combination of traditional
medicine, western medicine,
and prayer when confronted
with illness. The nature of
the illness determines which
approach is taken. Western
medicine is typically used
during emergency and
preventative care as
practiced in their homeland.
When western medicine is
unsuccessful in treatment or
diagnosis traditional
medicine is consulted. There
is a general lack of trust
relating to western
practitioners. Prayers often
supplemented western
medicine approaches.
Buckley, Blanchard, &
Neill, 2000
Literature review Discusses the contributing
factors to PTSD and
discusses how PTSD affects
vigilance and cognitive
processes.
Carroll, Epstein, Fiscella,
Volpe, Diaz, & Omar, 2007
A descriptive design was
used to assess the
experiences and beliefs of
34 Somali refugee women
about health promotion and
about health care services to
prevent disease in the
United States
Reports participants
demonstrated good
knowledge of U.S.
preventative health
guidelines including healthy
diet, regular exercise, access
to primary health care
services, and avoidance of
117
risky health behaviors such
as alcohol and tobacco.
Participants had low levels
of understanding related to
preventative health services
such as cancer screening.
Religion and spirituality
played a major role in the
adoption of health
promotion beliefs and
attitudes.
Murphy, Sahakian,
O’Carroll, 1998
Expository Identifies and discusses
depression as a contributing
factors in attention, short-
term memory, and cognitive
processes.
Palinkas, Pickwell,
Brandstein, Clark, Hill,
Moser, & Osman, 2003
Expository Identifies access points for
Somali and East African
refugees, wellness beliefs
and practices, and methods
for health promotion and
education.
Pavlish, Noor, Brandt,
2010
Qualitative social action
design; six focus groups
composed of 57 Somali
women along with 11 key
healthcare informants were
interviewed
Concludes Somali view
health and illness from a
holistic perspective. Women
expected a meaningful
relationship with providers
and had limited
understanding of disease
management. Somali
women had clear
expectation for diagnosis
and cure when seen by
providers. Language
differences significantly
impacted trust and
relationship with providers.
Read, Emerson, & Tarlov,
2005
A descriptive non-
experimental study to
examine the heterogeneity
of the black immigrant
population within the
United States in relation to
health disparity; researchers
used merged data from the
National Health Interview
Reports the health profile of
black Americans
demonstrates heterogeneity
with regard to country of
origin with black
immigrants from Africa
reporting superior health
over white Americans, and
black immigrants from the
118
Survey (NHIS); the sample
included 85,707 U.S.-born
whites, 16,891 U.S.-born
blacks, and 2015 foreign-
born blacks; of the foreign-
born blacks, 427 (21.2%)
were born in Africa
West Indies and European
nations.
Shelp, 2004 Descriptive, non-
experimental design to
measure the effectiveness of
a Somali doula initiative; a
survey of 26 registered
nurses; an additional survey
of 104 birth records from
2002–2004
Concludes nurses who
worked with Somali doulas
demonstrated greater levels
of cultural competence and
care. A reduction in
caesarian birth was noted.
Healthcare provides that
shared similar cultures were
effective in improving
patient outcomes.
Simmelink, Lightfoot,
Dube & Blevins, 2013
Qualitative study to
understand the health
beliefs of East African
refugees in the Minneapolis,
MN, area; 15 participants in
two focus groups were
interviewed
Concludes that refugees
maintain strong cultural
practices and beliefs related
to religion, social support,
food and traditional
medicine. Healthy behaviors
are challenged as
acculturation occurs.
Tiong, Patel, Gardiner,
Ryan, Linton, Walker,
Scopel, Biggs, 2006
Descriptive quantitative
study
Surveys the records of six
general practice physicians
in Australia to determine the
most common health
problems among African
immigrants. Most common
countries of origin were
Sudan and Liberia. Most
common problems noted
were lack of vaccination,
vitamin D and iron
deficiency, GI infections,
schistomsomiasis, latent TB,
and dental disease.
Vaughn & Holloway, 2010 Qualitative design to
understand the health
beliefs and practices of
Africans and West Africans
to better serve African
immigrant children in
Cincinnati; 10 West African
Reveals four themes:
pediatric healthcare practice
and expectations including
barriers, cultural values and
identity, health beliefs and
traditions/customs, and
quality of life.
119
parents were interviewed
Venters & Gany, 2010 Literature review Summarizes findings related
to health practices and
beliefs of African
Immigrants in relation to
mortality, infectious disease,
chronic disease, female
circumcision, mental health,
health insurance, nutrition,
traditional medicine.
Nursing Practice in
Africa
van der Doef, Mbazzi, &
Verhoeven, 2011
Cross-sectional descriptive
design to explore job
conditions, job satisfaction,
somatic complaints, and
burnout in East African
nurses; the sample consisted
of 309 female nurses
working in both private and
public hospitals within the
countries of Kenya,
Tanzania, and Uganda
Reveals East African nurses
identified high levels of
depersonalization and
emotional exhaustion.
However, higher levels of
social support, decisional
latitude, and sense of
personal accomplishment
were reported. East African
nurses experience high
levels of burnout according
to Western definition.
REVIEW OF LITERATURE AS IT RELATES TO FINDINGS
Academics
Amaro, Abriam-Yago, &
Yoder, 2006
Grounded theory study. 17
participants: 8 Asian, 4
Latino, 2 Portugese, 1
African American, and 2
native African
Identifies academic needs as
a major theme. Study
workload and time needed
for studies was identified as
a barrier. Translation of
nursing content to native
language was necessary for
understanding and takes
additional time.
Brown, 2008 Mixed methods study of 35
ESL students enrolled in a
baccalaureate nursing
program. Participants were
primarily from Africa
(Ghana, Ethiopia, Nigeria,
and Kenya) as well as from
the Philippines, Vietnam,
Mexico, Panama, and the
Caribbean Islands
Reports that participants
identified reading and
interpreting multiple choice
test questions as the most
difficult aspect of the
nursing program.
Therapeutic communication
is culture bound.
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Caputi, Engelmann, &
Stasinopoulus, 2006
Qualitative study of seven
English-as-another-
language nursing students
enrolled in a single
associate degree nursing
program. Countries of
origin include Poland,
Mexico, China, and the
Phillippines
Reports that participants
identified timed tests as a
barrier due to the time
needed to translate material
into their native language.
Multiple choice testing was
identified as a barrier along
with the use of slang words
and abbreviations in
academic materials and
lectures.
Fernea, Gaines, Brathwaite,
& Abdur-Rahman, 1994
Descriptive study using
entrance test data of 173
students in a baccalaureate
nursing program. 24
participants were from
Africa.
Concludes that the accent,
habits, customs, and beliefs
of culturally diverse
students make them hesitant
to speak up in class or
actively participate in class
discussions.
Mulready-Shick, 2013 Hermeunetic
phenomenological study
with six participants
originating from Central
America, South America,
and Africa
Reports that participants
identified learning medical
terminology along with
English language took more
time. Language affected
participant’s confidence in
asking questions and
participating in class and
approaching faculty for
assistance.
Napierkowski & Pacquiao,
2010
Qualitative study to
understand the perceptions
of barriers to and facilitators
of academic success.
Sample consisted of 12
students enrolled in an
accelerated BSN program.
Reports that participants
discussed the need to
translate information into
their native language.
Giving immediate response
to questions was difficult
because of the time needed
to process the content in
their native language. The
need to translate material
results in the need for
additional time for studying
and exams. Students had
difficult with multiple-
choice exams because their
educational experience was
based on essay type
assessment and focused on
121
memorization. Multiple-
choice questions did not
exist in their country of
origin.
Starr, 2009 Meta-synthesis of 10
qualitative studies relating
to educational issues of
nursing students with
English as an additional
language (EAL)
Concludes that students who
think and process in their
native language require
more time for testing and
written work. Other
academic challenges
included lack of orientation
to the academic setting, the
need for study groups, and
the volume of coursework.
Relationships
Amaro, Abriam-Yago, &
Yoder, 2006
Grounded theory study. 17
participants: 8 Asian, 4
Latino, 2 Portugese, 1
African American, and 2
native African
Reports that very few
participants experienced
prejudice from faculty.
Some experienced prejudice
from classmates. Many
encountered prejudice in the
clinical setting. Participants
identified language as the
primary sources of
discrimination. All
participants received
emotional and motivational
support from nursing faculty
and many identified one
faculty member that reached
out to them. Peer support
was a “major pillar” of
support for
]the participants.
Relationships with peers,
faculty, and family had both
a positive and negative
effect.
Cho & Auger, 2013 Quantitative survey of 156
public relations major
students.
Concludes that students who
have quality interactions
with faculty are more
satisfied with their academic
department and program,
have a greater commitment
to the program, and
demonstrate greater
122
empowerment.
Fernea, Gaines, Brathwaite,
& Abdur-Rahman, 1994
Descriptive study using
entrance test data of 173
students in a baccalaureate
nursing program. 24
participants were from
Africa.
Concludes that culturally
diverse student prefer
learning in groups.
Gardner, 2005 Qualitative study of 15
minority baccalaureate
nursing students. Sample
included East Indian,
Hispanic, Hmong, African
American, African, Filipino,
Nepalese, Vietnam, and
Chinese students.
Concludes that participants
experienced racial
segregation due to cultural
and language differences.
Participants felt that White
students perceived them as
less valuable and as a result
they felt de-valued.
Participants described
supportive faculty as those
that took an interest in,
provided emotional support,
and treated them as an
individual with unique
needs.
McEnroe-Petitte, 2011 Expository Argues for caring as a
foundation for nursing
curriculum. Faculty need to
take a personal interest in at-
risk students to bolster self-
confidence in the students.
Mulready-Shick, 2013 Hermeunetic
phenomenological study
with six participants
originating from Central
America, South America,
and Africa
Reports participants felt
unappreciated and de-valued
due to their accent and
language differences.
Participants focused on
connecting with peers
Napierkowski & Pacquiao,
2010
Qualitative study to
understand the perceptions
of barriers to and facilitators
of academic success.
Sample consisted of 12
students enrolled in an
accelerated BSN program.
Reports participants felt
they lacked the social
support of the family and
meaningful social
connections in general.
Participants perceived
faculty as unwilling/unable
to understand their
obligations.
Faculty and student interest
in participants’ cultural
differences provided
123
affirmation, sense of
belonging, and motivation
Participants feared speaking
up in class due to language
and cultural differences.n.
Sanner, Wilson, & Samson,
2002
Qualitative study to explore
the perceptions and
experiences of 8 female
Nigerian students enrolled
in a baccalaureate nursing
program.
Reports participants’ strong
accent contributes to social
isolation both inside and
outside of the classroom.
Participants felt they were
perceived as un-intelligent
and of no value in group
participation.
Shelton, 2003 Descriptive study to explore
the relationships between
students’ perceived faculty
support and retention.
Samples consisted of 458
associate degree nursing
students.
Concludes students who
reported greater perceived
faculty support were more
likely to persist throughout
the nursing program than
those that withdrew either
voluntarily or through
failure.
Starr (2009) Meta-synthesis of 10
qualitative studies relating
to educational issues of
nursing students with
English as an additional
language (EAL)
Concludes lack of language
skills may lead classmates
and faculty to believe EAL
students are less intelligent.
Participants also
experienced social isolation
in regard to peers, and
insensitivity and
discrimination from faculty.
Participants described
supportive faculty as those
that reach out, listen, and
respect cultural differences.
Wong, Seago, Keane, &
Grumbach, 2008
Quantitative study to
determine if race/ethnicity
affect students’ perceptions
of Institutional,
Dispositional, and
Situational factors. 1,377
students from 12 california
colleges and universities.
Participants identified
themselves as White,
African American, Latino,
Asian, Filipino, Southeast
Concludes African
American students from all
institution within the study
had less interaction with
faculty and peers. It is
unclear whether the African
American sample included
black African students.
124
Asian
Competing Demands
Amaro, Abriam-Yago, &
Yoder, 2006
Grounded Theory study. 17
participants : 8 Asian, 4
Latino, 2 Portugese, 1
African American, and 2
native African
Concludes participants
continued to carry the most
or all of the financial and
care-giving responsibilities
of family. Some participants
received financial and
emotional support from
family that helped to lessen
competing demands.
Fernea, Gaines, Brathwaite,
& Abdur-Rahman, 1994
Descriptive study using
entrance test data of 173
students in a baccalaureate
nursing program. 24
participants were from
Africa
Concludes culturally diverse
participants had
significantly more perceived
family and worklplace
stressors than American-
born students. African
students discussed strong
ties to family in homeland.
Mulready-Shick, 2013 Hermeunetic
phenomenological study
with six participants
originating from Central
America, South America,
and Africa
Reports participants
recognized the impact of
work on their academic
progress and reduced work
hours to be more successful.
Familial responsibility in the
homeland was a stressor for
participants.
Napierkowski & Pacquiao,
2010
Qualitative study to
understand the perceptions
of barriers to and facilitators
of academic success.
Sample consisted of 12
students enrolled in an
accelerated BSN program
Reports obligation to care
for and support family back
home was identified as a
competing demand.
Starr, 2009 Meta-synthesis of 10
qualitative studies relating
to educational issues of
nursing students with
English as an additional
language (EAL)
Report lack of financial
support and financial aid
required students to work
and was identified as a
challenge to educational
success. Many participants
were single parents or
supporting other members
of their family.
Culture
Amaro, Abriam-Yago, & Grounded Theory study. 17 Conclude speaking up and
125
Yoder, 2006 participants : 8 Asian, 4
Latino, 2 Portugese, 1
African American, and 2
native African
being assertive in asking
questions can be perceived
as rude in their culture.
Olson, 2012 Systematic review of
literature concerning ESL
nursing student success
Conclude culture and
language differences
resulted in students feeling
apprehensive to participate.
Therapeutic communication
is influenced by culture and
can affect performance on
exams.
Starr, 2009 Meta-synthesis of 10
qualitative studies relating
to educational issues of
nursing students with
English as an additional
language (EAL)
Conclude culture can
influence what students
learn and how they respond
to the information being
presented. Cultural
differences made it difficult
for participants to speak up
and be assertive in class.
Optimistic Determination
Amaro, Abriam-Yago, &
Yoder, 2006
Grounded Theory study. 17
participants : 8 Asian, 4
Latino, 2 Portugese, 1
African American, and 2
native African
Report all participants
demonstrated self-
motivation and
determination as a means of
coping with barriers.
Participants persisted
despite obstacles.
Batykefer-Evans, 2013 Exploratory survey to
explore the predictive value
of non-cognitive variables
on the intention of minority
baccalaureate students
Report minority students
had higher intention to
complete their nursing
program than non-
minorities.
Mulready-Shick, 2013 Hermeunetic
phenomenological study
with six participants
originating from Central
America, South America,
and Africa
Conclude participants
overcame doubt and anxiety
with acts of determination,
diligence, and resolve to
succeed.
Napierkowski & Pacquiao,
2010
Qualitative study to
understand the perceptions
of barriers to and facilitators
of academic success.
Sample consisted of 12
students enrolled in an
accelerated BSN program.
Identifiy personal ambition
and self-determination as
facilitators of success.
126
Sanner, Wilson, & Samson,
2002
Qualitative study to explore
the perceptions and
experiences of 8 female
Nigerian students enrolled
in a baccalaureate nursing
program.
Conclude participants
demonstrated persistence
despite obstacles and were
internally motivated to
assimilate with peers, and
balance work and school.
Optimism was displayed by
“keeping an open mind” to
challenges and barriers that
occurred. Participants were
described as hard-working,
motivated, goal-oriented and
determined.
Starr (2009) Meta-synthesis of 10
qualitative studies relating
to educational issues of
nursing students with
English as an additional
language (EAL)
Identify participants’ inner
strength and motivation as
their greatest resource.
Participants were described
as self-motivated, and
persistent.
127
APPENDIX B
DEMOGRAPHIC QUESTIONNAIRE
1. Name:
2. Current Age:
3. How old were you when you first enrolled
in a nursing program?
4. What brought you to the United States?
5. What is your country of origin?
6. How long have you lived in the United
States?
7. How long had you lived in the United
States when you first began your nursing
education?
8. What was your pre-licensure nursing
degree? (i.e., associate, baccalaureate,
diploma)
9. Do you have a degree in fields other than
Nursing? Yes No
10. What was your primary language spoken
while you were enrolled in a nursing
program?
11. Did you speak any addition languages
while you were enrolled in a nursing
program?
a. If yes, list any additional languages
spoken
12. Did you work while you were enrolled in
a nursing program?
b. If yes, where and how many
hours?
128
APPENDIX C
INTERVIEW QUESTIONS
1. Tell me about your nursing program experience.
Prompts
1. Tell me about your teachers, classmates, classes, and assignments.
2. What helped to support you in your nursing program?
3. How was your actual experience with your nursing education the same or different
than your expectations for the program?
4. Tell me about a time when you felt particularly discouraged in your nursing education.
Follow up: How did you resolve this problem/situation/challenge?
5. Tell me about a time when you felt empowered/encouraged/inspired during your
nursing education
6. What was your most significant accomplishment during your nursing education?
129
APPENDIX D
RECRUITMENT FLYER
130
APPENDIX E
INFORMED CONSENT AND AUDIO TAPING CONSENT
INFORMED CONSENT
Department of School of Nursing
TITLE OF STUDY: The Lived Experience of Black African Nurses Educated in the
United States.
INVESTIGATOR(S): Dr. Patricia Smyer, DNSc, RN
For questions or concerns about the study, you may contact Dr. Patricia Smyer at
702/895-5952.
For questions regarding the rights of research subjects, any complaints or comments
regarding the manner in which the study is being conducted, contact the UNLV Office of
Research Integrity – Human Subjects at 702-895-2794, toll free at 877-895-2794 or
via email at [email protected].
Purpose of the Study
You are invited to participate in a research study. The purpose of these study is to gain
an understanding of how black African immigrant and refugee nurses experience nursing
education within the United States.
Participants
You are being asked to participate in the study because you fit this criteria: have
emigrated from a sub-Saharan African country and have graduated from a United States
based undergraduate registered nurse program.
Procedures
If you volunteer to participate in this study, you will be asked to do the following:
Participants will agree to a face to face, audio-taped interview. In addition, the
participants will agree to a follow-up interview which will be used to clarify any errors of
the verbatim transcription, misinterpretations of researcher regarding themes, and allow
131
participants an opportunity to add any additional thoughts they may have had about their
lived experiences. Participation is voluntary and confidential. Each interview will last
approximately one hour and will be held at a private location that is convenient for the
participant.
Benefits of Participation
There may not be direct benefits to you as a participant in this study. However, we hope
to gain insight into factors that affect the recruitment and retention of black African
immigrant and refugee nursing students in nursing programs in the United States. This
information can help nurse educators and administrators to make targeted changes in
curriculum and policies that support diverse students. Increasing the number of black
African immigrant and refugee nurses is important to provide culturally sensitive care.
Risks of Participation
There are risks involved in all research studies. This study may include only minimal
risks. Participants may experience some emotional discomfort while discussing the
feelings associated with school experiences. There will be an assurance that the
participants may withdraw from the study at any time without penalty. This is no risk for
declining participation.
Cost /Compensation
There will not be financial cost to you to participate in this study. The study will take
approximately 2 hours of your time. You will be compensated for your time through gift
cards. A $10.00 gift card will be given to you at the completion of the 1st interview. A
$15.00 gift card will be given to you at the completion of the 2nd
interview.
Confidentiality
All information gathered in this study will be kept as confidential as possible. No
reference will be made in written or oral materials that could link you to this study. All
records will be stored in a locked facility at UNLV for 3 years after completion of the
study. After the storage time the information gathered will be destroyed.
Voluntary Participation
Your participation in this study is voluntary. You may refuse to participate in this study
or in any part of this study. You may withdraw at any time without prejudice to your
relations with UNLV. You are encouraged to ask questions about this study at the
beginning or any time during the research study.
Participant Consent:
132
I have read the above information and agree to participate in this study. I have been able
to ask questions about the research study. I am at least 18 years of age. A copy of this
form has been given to me.
Signature of Participant Date
Participant Name (Please Print)
Audio/Video Taping:
I agree to be audio or video taped for the purpose of this research study.
Signature of Participant Date
Participant Name (Please Print)
133
APPENDIX F
DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS
Charlie Dan Debra Emma Grace John Katherine Mike Ryan
Sex Male Male Female Female Female Male Female Male Male
Age * 25 33 22 19 26 31 36 27 30
Country of Origin
Kenya Eritrea Liberia Kenya Ethiopia Ethiopia Sierra Leone
Kenya Kenya
Program Type
ASN ASN ASN BSN BSN ASN ASN ASN BSN
Years of Residency**
3 1 <1 < 1 2 1 5 1 1
Primary Language***
English Tipripna English English Amharic Amharic Mendé Kiswahili, Kisii
Swahili
Reason for Immigration
Visa Lottery
Refugee War Study Purposes
Family Diversity Visa
Family Study and
Work
Green Card
Other Degree
No No No No No Yes No Yes Yes
Hours Worked
Full Time
20 +/wk 60 hrs/ pay
period
40/wk 0 24 hrs/ wk
16 hrs/ pay-period
Full Time
24/wk
*Age refers to the age of the participant at the start of their nursing program.
** Years of residency refers to the number of years the participant had lived in the United States
when they began their nursing education.
***Primary language refers to the language participants spoke most frequently at the time they
were enrolled in the nursing program.
134
APPENDIX G
IRB APPROVAL
135
APPENDIX H
COMPARISON OF SANNER ET AL. (2002) AND SMITH (2014)
Criteria Sanner, Wilson, & Samson (2002) Smith (2014)
Sample Eight female Nigerian baccalaureate
nursing students
Nine practices nurses (4 female, 5 male)
from Nigeria, Kenya, Ethiopia, Eritrea,
and Sierra Leone. Pre-licensure
education was at both associate degree
and baccalaureate level programs.
Purpose “To explore the perceptions and
experiences of international nursing
students after their junior year of study in a
baccalaureate nursing program” (p. 206).
To gain an understanding of how black
African nurses experience nursing
education in the United States.
Themes Themes: Social Isolation, Resolved
Attitudes, Persistance Despite Perceived
Obstacles
Overall Essence: Optimistic
Determination.
Themes: Academics, Relationships,
Competing Demands, Culture
Comparison
of Themes
Social Isolation
All participants identified social
isolation and discrimination.
Social isolation occurred less often
in small clinical settings.
Language differences prohibited
students from becoming involved
in classroom and extracurricular
activities.
Participants felt American students
perceived them as stupid due to
language difficulties
Participants remained silent to
avoid feeling uncomfortable.
No relationships with faculty were
discussed.
Relationships
Participants described both
negative and positive
relationships with classmates.
Participants described less
discrimination and isolation in
the clinical setting.
Language differences were the
primary cause of relationship
issues.
Some participants expressed
that American students
perceived them as stupid.
Participants remained silent or
sought support from other
minority students when they
experienced discrimination.
Participants described positive
and negative interactions with
faculty.
Participants described
supportive faculty as those who
showed a personal interest in
them and respected their
culture.
Resolved Attitudes
Participants resolved themselves
that the attitudes of American
students could not be changed.
Optimistic Determination
Participants reported “going
with the flow” when
relationship difficulties arose.
Persistance Despite Perceived Obstacles
Participants were determined to
make necessary changes to be
successful.
Participants maintained
Optimistic Determination
Participants reported their main
support came from within and
was their determination and
optimistic thinking that helped
136
persistence by keeping an open
mind and accepting differences.
them to overcome obstacles.
Persistance Despite Perceived Obstacles
Participants worked in healthcare
to gain experience and pay tuition.
Family obligations were not
discussed.
Competing Demands
Most participants worked at
least part time to support
themselves and their families in
Africa.
Participants discussed family
obligations as an additional
stressor.
Culture
Participants described early
experiences with education and
nursing.
Participants discussed family
responsibilities in Africa.
Academics
Multiple-choice testing was a
difficulty for most participants.
Language differences resulted
in participants needing more
time to study and test.
Language and cultural
differences made test questions
difficult.
Some participants experienced
difficulty with technology.
137
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CURRICULUM VITA
Graduate College
University of Nevada, Las Vegas
Amy E. Smith
Degrees
MS, Walden University, 2007.
Major: Nursing Education
Practicum Project- Implementation of Simulation
BSN, South Dakota State University, 1998.
Major: Nursing
Professional Positions
Academic - Post-Secondary
Nursing Instructor, The University of South Dakota. (July 22, 2010 - Present).
Online Adjunct Faculty, The University of Phoenix. (May 2010 - August 2011).
Online Developer -Nursing, Globe University. (January 2010 - August 2010).
Nursing Faculty, South Central College. (January 1, 2007 - December 18, 2009).
Professional
Public Health Nurse, Mower County Public Health. (September 1999 - December
2006).
Staff Nurse, Austin Medical Center. (January 1999 - September 1999).
Licensures and Certifications
PHN, Minnesota Board of Nursing. (November 1, 1999 - Present).
RN, Minnesota Board of Nursing. (February 26, 1999 - March 31, 2016).
RN, South Dakota Board of Nursing. (February 14, 2011 - March 9, 2016).
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RN, New Mexico Board of Nursing. (January 19, 2011 - January 31, 2015).
Certified Nurse Educator, National League for Nursing. (April 19, 2011 - April
19, 2014).
RESEARCH
Presentations Given
Smith, A. E. (Panelist), Healthforce Minnesota PN Curriculum Workshop, "Panel
Discussion with Faculty using Concept Based Curriculum," Healthforce
Minnesota, Hennepin Technical College. (August 14, 2013).
Smith, A. E. (Presenter & Author), Wisconsin-Minnesota AHDI Annual Regional
Conference, "Ethical Issues in Health Care Information Technologies,"
Association for Healthcare Documentation Integrity (AHDI), La Crosse,
Wisconsin. (October 1, 2011).
Smith, A. E. (Presenter & Author), North Star Spring Symposium, "Ethical Issues
Related to Advanced Health Care Information Technologies," Association for
Healthcare Documentation Integrity (AHDI), Owatonna, MN. (May 24,
2011).
Dissertation
Title: The Lived Experience of Black African Nurses Educated Within the United
States
Dissertation Committee Members:
Chairperson: Tish Smyer, DNSc
Committee Member: Lori Candela, EdD
Committee Member: Alona Angosta, PhD
Graduate Faculty Representative: LeAnne Putney, PhD
SERVICE
Public Service
Member, Medical Reserve Corps, State of Minnesota. (August 2011 - Present).
